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Emergencies can be an intrusion into a busily scheduled day. Ruddle looks at the different types of emergencies and discusses how to manage them. Additionally, Dr. Ruddle discusses the popular obturation trend of using a single cone and BC Sealer. Why is this a thing and is it a good thing? Enjoy the wrap-up featuring Superlatives!
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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: John Ingle’s New Textbook
[Music playing] Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. Today on our show, we’re gonna talk about the different types of emergencies and how to assess them. Then, my dad is going to discuss the popular trend in obturation, of using BC sealer in a single cone. He’s gonna talk about why is this a thing and is this even a good thing. And then, we’re gonna close our segment with something we call “Superlatives”, and you’ll see what that is when we get to it. But first, you received something pretty interesting in the mail this week. Why don’t you tell us what that was.
Thank you. Yes. I received Ingle’s Endodontics’ 50th-Anniversary Editions. There’s two of ‘em, Volume I and Volume II.
And the 7th Edition.
Yeah. It’s the 7th Edition. So, you know, I was proud of it because I’ve been – I have quite a few of his books in my library. I don’t think I have all of ‘em, but I have at least four of ‘em I counted. And Ilan Rotstein, Professor Rotstein asked me some time ago – he’s a coauthor with Ingle. He said, ‘Can we use some of your 3D animations as a color plate for our cover?’ So, maybe they could bring up the image of the first and the last. So, it was a great opportunity, because what we could do is kind of show a more sophisticated kind of textbook cover, where we look at actual 3D anatomy of human teeth. But you look back at the old one, in ’65, his 1st Edition --
And that was your textbook in dental school, right? [laughs]
-- oh, absolutely. In fact, at the University of the Pacific, in San Francisco, in dental school, that was what we affectionately got in our kit for our endodontic training. And I think many students in North America actually used this book. There are – you know, right now, younger dentists can look at a library of possibilities, and you can see countless textbooks. But there was only a very few, back in the day.
Well, you were actually pretty lucky, because it looks like you had to learn a lot less stuff. Because now, I see that there’s actually two volumes here, and it looks like there’s a lot more endodontic information [laughs] than there used to be [laughs].
Well, you know, the old adage that ‘Knowledge doubles or triples every two or three years’ is true, and it’s happened in endodontics. In fact, in endodontics, there’s just so much more today, with the technology that’s driven many new practice-building techniques. So, to capture all that stuff, it takes more printed spaces. In fact, Ingle was famous – if you look at the collaborators, there might be, I’m guessing, 30 or 40 clinicians who contributed to chapters. Well, Ingle was famous for wanting to get you or somebody else involved with your expertise in something that you were passionate about, and then he wanted you to reduce it to words and get it into a text. Very nice books, very nice color. I guess I’d like to say three things that impressed me about Ingle’s life. First of all, he was married for a very long time, so I thought that was cool. Almost 74 years, and his wife’s name escapes me. If you look in the cover, you might be able to --
-- Joyce. Joyce, his wife. In fact, she was the one who wanted an oversized book, 8 ½ by 11, ’65, and she said, ‘Let’s make it yellow.’ So, that was not normal in the day, because most medical and dental textbooks were very small books and didn’t have a lot of images and color plates. And so, they really made this one look different. It was different, and we learned different.
It looks like the 50th Anniversary is kind of back to yellow but maybe a more modern yellow. That’s a very 1960s yellow [laughs].
Yeah. And for those people who love orifice-directed access cavities, John was sensing it, even back in ’65.
Okay. So, three things that I can take away from Ingle. Number one, he started the first graduate program at Washington. It was – his training was at the University of Michigan, for endodontics and periodontics. So, he is a Boarded periodontist and a Boarded endodontist. And in fact, when he went back to Washington, he started the first endodontic program on the West Coast. What that means is, students came, research started being conducted, the research was published, and our base of foundation of knowledge began to grow. So, it spread a lot of interest. He moved from Washington after 16 years and went to USC. He was the Dean of the school at the University of Southern California. That was a pretty nice feather in his hat.
So, that was the one thing, the teaching part and the West Coast influence. The second thing is, he noticed, as a practitioner, that every company that made files, as an example, used their own standards. So, it was really crazy. You could buy a file from this company and this company, but they’d have different tapers, different flute lengths, et cetera, et cetera. So, he worked with the International Standards Organization to get all manufacturers of instruments to abide by a standardized manufacturing process, and it’s still used today.
The third thing was, him and Lars Strenberg [sounds like], in earlier textbooks, they basically gave us the Washington Study, because there was a lot of concern about was endodontics successful back then, and what would be the prognosis over time. So, John and Lars did a big study called the Washington Study, and they looked at success and failure of endodontically treated teeth. And they looked at ‘em over the years, and it was way up in the 90s, about 94 percent success when properly performed. They also, then, looked at the reciprocal failure rate. And they wanted to know why cases fail.
So, they looked at ledges and blocks and perforations and broken instruments and missed canals and all the stuff we see in the world of re-treatment. And they outlined those in a very beautiful way. So, our profession learned an awful lot about endodontic prognosis and then, why cases fail.
I know he was also a good friend of yours. I think we have a picture of you and Mom with John Ingle. So --
Oh! So, here’s Phyllis. We hit 52 years. I’m still in his draft. He was almost 74 years to Joyce, but here’s Phyllis and I. And where we are is, we’re in Canada, and we’re at the Canadian Academy of Endodontists, C-A-E. And this was John’s, it turned out, because he passed away in 2017, but this was his last meeting he ever attended. And so, that’s a group picture of us, and you can see even at 98 years old, he’s got that little gleam in his eye. And that’s the mentor and friend we all loved.
-- oh, this – he is 98 years old, in that photo? [laughs]
He’s – if he’s not, he’s 97.
Or 150? No [laughs].
No, I always remember, because he was within two years of my pop.
Well, it’s pretty amazing. Let’s – do we have the picture of all of the textbooks that he did? When you think of this one, from 1965, all the way up to now, to 2019, and you think of the time period he lived, pretty much he would have had to live in the time period he lived, to even make this possible, because it would be hard to do something like this, starting today. Because textbooks are becoming more and more obsolete. Like, this was published in 2019, this year.
But the process and getting all of – to prepare for publication, probably a lot has already changed, since these just came out. Because information is so accelerated nowadays. So, probably he lived in a very unique time period to even have the opportunity to have this body of work and do the things that you said.
You know, Lisette gave me some books. I’ve talked about ‘em on other segments. But it was a group of four groups by Malcolm Gladwell, and the first one is called “Outlier”. And in the book “Outlier”, you realize that nothing happens by chance. You look at great baseball players, hockey players, you look at high-rise towers around the world, and when they started, always started when people had some fundamental knowledge and were willing to work hard, and then technology arrived. So, to your point, I don’t know that this will ever be repeated, because I don’t think – as an example, if I started writing textbooks now – well, first of all, I’m [laugh] – I’m getting a little bit old.
But I’d have to have quite a run, and it’s not how the world’s working. To your point, a lot of these books have CD-ROMs in ‘em, and you can be online, zoom around in chapters. I mean, I just about pulled out my shoulder, carrying those books over here this morning. So, you know, it’s a lot of knowledge, but it’s a wonderful tribute, and certainly Ingle has impacted our profession.
Well, that sounds like – it’s just some really great information and interesting. But let’s get started with our show now. [Music playing]
SEGMENT 1: Specific Scenario – Assessing an Emergency
Today, we’re gonna talk about the dental emergency, as you can see from the sign behind us. Emergencies can represent an intrusion into a busily scheduled day. In terms of endodontics, how can the dental team know if the patient is a true emergency versus a non-emergency?
That’s a great question, because you can save a lot of time in a day if you have your team trained up. So, probably, let’s start right on the first line of offense, would be the lady who usually answers the phone, sometimes called a receptionist. And if the --
And it could be a man. [laughs]
-- it certainly could, because I’ve talked to some of them. These people can really help schedule this properly, if they just ask a few questions. And one question I think is really important is, ‘How long have you been hurting?’ ‘Well, I’ve been hurting for about three or four days, now.’ Well, that’s a different thing than, ‘It’s been hurting for the last two or three months.’ So, ‘How long have you been hurting?’ ‘How bad does it hurt?’
So, let’s kinda quantify it. Zero is perfect, you don’t know you have teeth, and 10 is the worst you can imagine. So, on the phone, I’d like to find out from the patient, ‘On a scale of 0 to 10’ – it’s their truth, not your truth, ‘Where do you put yourself?’ So, if people start to say it’s a two or a three, then, that gives me permission to say to the receptionist, to have her relay to the patient, ‘Would it be okay if we saw you tomorrow or the following day?’ So, if they say, ‘It’s like a 9 or a 10, I didn’t sleep last night’, it’s like, basically, ‘Come right over.’
I like how you said that you’re gonna ask a question, if it was a two or a three, ‘Would it be okay?’ Because some people might just still insist, ‘I need to come in, because maybe my pain isn’t so bad, but I’m just really afraid it’s gonna get worse.’
Yeah. We always have to ask permission. If you must speak, ask permission, or ask a question, because if you – if you must speak, ask a question. Because if you ask a question, questions are the answers. It lets people interact with you and it starts to build trust and confidence.
I think if you said, like, ‘The doctor’s really busy today. And since your pain is only a two or a three, we’ll schedule you in a couple days.’ That might not go off as well. [laughs]
Exactly. So, you wanna know how long they’ve been hurting, how bad it hurts, and then, if you can, as a thoughtful question. ‘Is there a stimulus that provokes the pain?’ In other words, don’t say, ‘Hot and cold.’ Say, ‘Do you have any problems with cold liquids?’ Zip. Because if you say, ‘hot or cold’, and they give you an answer, you got stupid information, because it’s a stupid question, because you don’t know if it’s hot or cold.
So, if they say it’s hurting to cold, we already know, on the phone, that it’s a vital tooth, because vital tissue reacts to cold. So, that’s gonna be a different kind of an emergency for me, in my mind, than if they say, ‘No, actually, coffee kills me. Pizza, soup.’ It’s the hot coffee that stimulates the pain. Well, that’s gonna be more like a necrotic tooth, and that’s gonna be probably even handled different. So, how long has it been hurting, how bad does it hurt, and is there a stimulus? ‘Can you bite on your tooth? [Clacks teeth together] Can you chew equally well enough?’ [sounds like] ‘No, no, it’s really sore, feels like it’s the first tooth to hit.’
Well, now you probably know that there’s periradicular extension, so the disease has left the tooth, and now it’s out into the attachment apparatus. So, when we load the tooth, tooth moves against the injury, and it hurts. So, those are three questions that can really help. Obviously, is it an upper or a lower? They can usually tell you that, and you might even say – the receptionist could even say, ‘Is it towards the front, or does it seem like it’s towards the back?’ Because all those, on an emergency, it’s a little [laughs] easier to handle that one than this one, because of the numbers of canals and things.
So, basically, if you begin to have the receptionist ask those key questions, you’re gonna be able to put ‘em in a slot, where you can be pretty definitive and really take care of, in a definitive way, their crisis.
What about like maybe if they’re taking medication, is that important to know?
Oh, thank you. Some people are heavily medicated. They might have been medicated in a dental office. They could have even been given an injection and then say, ‘Call Ruddle’, as an example. So, they are not [laughs] gonna respond very well to 0 to 10 and all that. So, if you found out they were anesthetized, you might say, ‘Before you were anesthetized’, and then, you can start repeating those questions. Also, people take pain pills over the counter, or they have narcotics, and they can be on those. So, that’s a good thing to know. Yes.
Okay. So, are there different types of – and I heard you say ‘vital’ and ‘necrotic’. Maybe, can – what are the different types?
Okay. Let’s take out of this story traumatic episodes.
Car accidents, baseball injury, elbow in the paint, those can be quite time consuming. But for me, if you discount trauma, there’s three kinds of emergencies. There’s vital emergencies. There are necrotic emergencies. And then, in the case of endodontic failure, there’s cases that break down and fail over time, and those are emergencies. So, that’s the three kind of emergencies I recognize.
Well, tell us about vital emergencies and how you would manage those.
Well, when they say on the phone, ‘Cold kills me’, sometimes they’ll even say, ‘Warm water turns the cold pain off.’ You know that that’s gonna be a tooth that’s vital, it’s going to bleed excessively when you open it. There could even be anesthetic issues. Get them profoundly numb. And so, one tip [laughs] I’d really like to tell the audience is, when you reproduce the chief complaint – and we’ve done other episodes that we can refer the colleagues to, to go get information on the vital pulp test, hand signals, and how to record this information.
But given all that, essentially what you wanna know in vital emergencies is, you test the tooth last. So, you would get a baseline, contralateral teeth, opposing teeth, and then, do the tooth you suspicion, the culprit tooth, last. If you provoke a huge pain with cold, okay. Now, everybody knows you got the tooth. So, then, you usually follow up with anesthesia. And let’s just say for fun it’s a lower mandibular molar. So, they say the lip is getting profoundly numb. They’re starting to talk like this [speaking as though his lips are numb] because they’re so numb. Their tongue’s numb.
So, all of a sudden, you’re going, ‘Okay. Let’s isolate.’ And you just told a patient, ‘We do endo all the time. It goes very, very well. I am the King of Endodontics, and my patients never hurt.’ So, you isolate the tooth, because they’re profoundly numb. And you start to drill, and all of a sudden, they’re jumpin’ around in the chair. So, that means they’re not properly anesthetized. So, what the trick is, is once you have the patient profoundly numb, come back and retest the tooth with a cold stimulus, and see if they feel it. If they feel it, you’re gonna need auxiliary anesthetic, like Stavadent [sounds like] or an interligamentary injection, to get another level, a higher level of profound anesthesia.
Achieving anesthesia, is the difficulty to achieve anesthesia -- is that something that happens often with vital emergencies?
It seems to happen a lot more with vital emergencies and mandibular teeth. And there’s collateral enervation to these teeth, and sometimes it takes some supplemental anesthetic, to really make things quiet. I always put people in charge, so, for 45 years, I always said to a patient, not ‘If you feel anything’. Come on! They’ll say, ‘I feel a breeze from the air conditioning vent.’
So, you say to them, ‘If I exceed your comfort zone at any time, just raise your hand, and I’ll stop.’ And then, be your word [emphatically]. If they raise your hand, stop.
And then, I think you said something about bleeding, too, like – is that --
Okay. So, vital emergencies should be anticipated, even from the phone call. So, if the – if the audience is thinking back to the receptionist that asks these questions, there could be an anesthetic issue. She should anticipate that, when she schedules. She should understand that when you open up the tooth, it’s probably gonna bleed like crazy. Well, if she knows it’s an – a front tooth more, you know, anterior tooth, then there’s probably one or two canals. If she decides that the patient reports it’s a posterior tooth, then, there could be multi0canals. There could be three, four canals.
So, when you open it up, and there’s a lot of bleeding, which canal do you choose to clean? Because really, to remove inflammatory tissue, we go to the ones that are bleeding the worst. So, if you open up a maxillary molar, and blood’s gushing out of the palatal canal, that’s the one, in a limited amount of time, that I’m gonna be pretty thorough and clean that out. Now, I’m not doing big-league, high-level cleaning and shaping, but I’m getting to length, I’m getting an apex locator or film that says I’m at length, I’m making the amputation apically, and the canal is not bleeding when I provisionalize and dismiss the patient.
So, you wouldn’t just do the whole endodontics, at that visit. You would actually just clean it out and have them go away for a few days?
I think your question is, and I’m gonna exaggerate, to make a point --
-- because I’m asked this a lot. So, I’m anticipating maybe a little more what you might’ve meant. A lot of times, we’re busy. And you started this whole segment off, it’s an intrusion into an otherwise busily scheduled day. So, you really don’t have a lot of time. But wait a minute. Her question was, ‘What if you had a cancellation? What if you were at your office, and you weren’t with patients, and you were doing something else?’ On vital emergencies, you could do start-to-finish endodontics.
Okay. So, it’s a time --
You’re only limited by --
-- constraint. Okay.
-- exactly. So, when things bleed – so, anesthesia’s an issue, and then, getting the most inflamed tissue out is a good thing to do. And with our mechanical instruments today and emphasis on glide path, this can be done very, very effectively and quickly.
Well, how does a necrotic emergency differ, then?
Well, in necrotic teeth, typically there’s no vascularity. So, the pulp has died. But there’s still, oftentimes, residual enervation. So, when you put ice on these teeth, the patient doesn’t feel it. If you test it with hot, a lot of times you provoke a big response, because necrotic tissue has anaerobes, anaerobic bacteria. They’re gas producers. So, gases expand when there’s heat. So, you bathe your tooth with hot coffee, and the necrotic tissue, the gases from the microbes expand, and it pinches on a lot of nerves. So, it can be very painful. But they’re not gonna bleed.
So, the good news is, on necrotic emergencies, I pretty much know, when somebody says, ‘It hurts to heat’, on the phone, before they ever come in, I’m gonna be doing a pulpotomy. So, I’m gonna make an access, and I’m gonna amputate at the level of all the orifices, put a cotton pellet in dry, no medication, provisionalize, and [claps hands] dismiss the patient. So, necrotic emergencies can usually be handled with a pulpotomy only. Now, if you open up the necrotic tooth, and there’s productive drainage, then I leave those teeth open for two, three, or four days. And I place them on an antibiotic, because there’s active infection.
This is not the time to be instrumenting and getting blocked [laughs] and doing a lot of gymnastics. Remember, you have a limited time, and you wanna be really, really definitive. So, the pulpotomy works great, and close the tooth. If it drains, leave it open, and put a big cotton pellet – I even have little tear-off pads that I gave patients over decades, called Open Tooth Instructions. So, they don’t think you’re crazy. ‘What? You’re leavin’ a hole in my tooth?!’ So, all of a sudden, they’re going, ‘Am I gonna get a hamburger in there? Am I – I’m gonna drink a Coke, and it’s gonna get sucked down.’ No, it's not like that.
There’s a lot of time-honored research and information on this on the Web, and we’ve written about it, and you’ve published – helped me publish it. So, there’s a lot of background information that can help them, but oftentimes, just because you don’t see purulence doesn’t mean, ‘Close the tooth’. Because again, the gas producers are producing gases, and they’re not visible with your eye. So, a lot of times, if you [makes sniffing noises] smell putrescence in the operatory, a lot of times the patient’ll say, ‘Gee, what’s that smell?’ And you go, ‘Well, that’s why you’re here, because you have --
-- a necrotic – yeah. You have a necrotic tooth.’ Necrotic tissue can be putrescent. So, I leave a lot of necrotic teeth open, because it’s just like axiomatic in medicine, I&D. So, you incise and drain. So, by leaving the tooth open, that’s your incision, and you allow it to drain. And again, to be redundant, the tooth is only left open two, three, four days, and they’re coming back while they’re on the antibiotic. And I oftentimes do start-to-finish endodontics on visit two.
Okay. So, what about the patient that has had endodontics, and it’s failing, and they’re in a lot of pain? How do you handle that emergency?
This is the easiest of all emergencies. It – you just need to make those human connections, to build trust and confidence. And what you’re gonna do, really, is, if it’s practical, you’re going to adjust the occlusion, on all the emergencies. I’m just now mentioning it for the failing tooth. But by adjusting the occlusion, a lot of times these teeth super-erupt because of the pressure from the infection, and it’ll push the tooth up, and it’ll feel long. And the audience knows that we can feel a hair between our teeth, and a hair’s like six hundredths of a millimeter. So, if your tooth is up like a quarter of a millimeter, it feels like you have a rock between your teeth, and you’re bangin’ on that sore tooth. So, if you can knock that tooth down by adjusting the occlusion, they’re a lot more peaceful.
So, what we really do is make the connection, we adjust the occlusion would be the only technical thing that I would consider doing. And then, I would give ‘em antibiotics and anti-inflammatories. We rarely give narcotics. They’re just not necessary. And the antibiotic will get loaded in, depending on which one, within a few hours. But certainly, within a day or two, you’ll start to have serum levels, so you can tell the patient they might not feel a lot better, so that’s why they’re taking the anti-inflammatories in the first 24 hours. But as the antibiotic kicks in, the pain begins to diminish, and patients respond nicely.
Then, while they’re still on the antibiotic, have them come back in, schedule accordingly, make space, have a flexible receptionist that can move people around. It’s a triage practice, endo, and so, you now can disassemble the tooth, and we’ve talked a lot about disassembly and the re-treatment. We’ve written chapters in books. But it’s a big deal. The point to make, though, Lisette, is, this is not the time, when they’re in acute pain, to be vibrating, boom, boom, boom, boom, boom, boom, boom, boom, with ultrasonics on a post to knock it out. It's not the time to be using solvents to dissolve gutta-percha.
These are just going to be super-imposed over an acute situation. And if you thought they hurt when they came in, wait till they leave. Ha, ha! This is not the practice builder you were thinking. So, do as little as you can, to get the best result.
Well, it sounds like, obviously, emergencies are unexpected, and it’s gonna require you to adapt. But is there anything good that can come from an emergency situation? Like, what good can come out of this?
Oh, profound good can come out of this. Dentists will tell you all over the world that they’ve built their practice when they were young and in their formative years, because of seeing emergencies. And most emergencies are endodontically related. So, people never forget when you turn off their pain. Now, the staff can really benefit. The staff has an opportunity to come together. Everybody’s on the same page. And boy, there’s like music. It’s like a beautiful thing, everybody knows what to do, where to be, and how to participate. But if we can offer compassionate and effective and painless emergency care, people never forget that.
And the staff can – you know, just a little touch or a little pat goes a long ways to – just to say, ‘I care. I give a damn.’ So, we should be able to have our staff do those three things, and then, we’ll earn respect and trust and confidence. And that’s what makes people go, ‘Well, you know, it wasn’t as bad as I had been told or that I thought.’
And I’ve also heard you say that it’s nice to follow up with them, like you call them later and have them talk to you about the experience and the situation. Because the more they can actually talk about it with you, in a positive way, then that’s gonna be how they’re going to go communicate it to others when they talk about their experience. And so, that’s good for your office, too. So, I think it’s – if you can handle it well, and then, it could help everybody communicate better and it could just be a good experience, I would think.
You know, Lisette, you didn’t realize it, but you’re a psychologist.
What she said is something that we used to teach in our two-day courses, but it’s called ‘Programming the patient for the desired response’. And that sounds pretty calloused, right? But let me be very specific. So, when you call the patient the night of treatment – so, we do this routinely, and I did most of it. You might remember, growing up, I was always on the phone for about 20 or 30 minutes, when I first got home. I called every single patient. The first thing you hear is, ‘Oh, I’m fine! Why – you didn’t need to call! I’ve never had a doctor call me, in my life! You’re the first one that’s ever called me!’ So, anyway, you get that.
But especially on emergencies, you do make that call, and if it – if you’re not available, or you’re traveling, and you’re outside the country, your staff makes that call. And basically, you ask them questions that are going to be able to be utilized by them subconsciously to explain to others what happened. So, you might say to the patient, ‘So, how’d it go today? Did all members of the staff treat you in a respectful way? Did you feel any pain? Did it go better than you thought? Did it go worse than you thought?’ And by having them say this back to you, it’s a powerful rehearsal for them to tell others.
Oh, that – that’s really actually some interesting stuff. I like it. So, let’s maybe go on to our next segment now, where you’re gonna talk about this new obturation trend.
Oh. I guess we can do that right now. But be sure to handle your emergencies. It’s a big part of being a practice builder, and patients never, never forget that it was you that came out on Christmas Eve and turned off the proverbial toothache.
The malady of human mankind. Okay.
SEGMENT 2: Obturation – Single Cone / BC Sealer
Earlier in the show, Lisette asked you a question. It wasn’t rhetorical. And here’s the answer. She wanted to know if, in fact, single cone with a bioceramic cement was a good thing. And so, I’d like to add a little comment on this, a little perspective that maybe you haven’t thought of. Because sometimes it’s easy to get caught up in fads, and fads come and go. Companies commercially get behind stuff, and all of a sudden you get the impression everybody’s doing it, but me. So, let’s look a little bit at that single cone with the bioceramics.
Bioceramics, of course, there’s many different kinds, with different brand names, by country. But as – they’re basically tricalcium, silicate-based materials. Okay? And they can have different formulations, subtly, but they all fall pretty much into those things. Some of them can have even calcium phosphate, which is known to help the material set up itself, and then, it’s an osteogenic material. It’s a scaffolding for bone. So, this has caught the attention of a lot of people worldwide. But first of all, let’s look at the assignment.
If we look at a model of a real tooth, it’s an animation. It’s 3D animation, modeled after a real tooth, with a real root-canal system. You can begin to see the assignment is somewhat challenging. Historically, of course, we would access the tooth, negotiate canals, make some kind of a preparation. We don’t agree on that, necessarily, the size and dimensions, but we all agree on some kind of a preparation. And then, we would have disinfection protocols, and then, of course, filling root-canal systems. So, when you look at the animation of a real model tooth, you begin to see that there’s a lot of very complicated, Hess-type anatomy inside the roots that hold these systems.
So, when you begin to think what we’ve learned over the past, it was lateral condensation. It was oftentimes vertical condensation or continuous wave. It might’ve been a carrier-based obturation idea. All those have been taught and advocated, and then, single cone kinda crept into the conversation. So, when you start to look at the anatomy behind me, you can begin to see, when we look at actual radiographs of cases that have been treated, you can see there are systems that look just like what we saw in Hess’s work and other of the micro-CT work that’s done around the world, pretty much routinely these days. So, those were the commonly employed obturation ideas.
And then, single cone came along. And of course, single cone was driven largely by minimally invasive endodontics. So, in minimally invasive endodontics, the shapes became quite a bit smaller. A lot of the armamentarium couldn’t fit effectively into the roots deep, to mold and adapt gutta-percha to the intaglio. So, the single cone became kind of a back-door way to fill a root-canal system. It’s used by a lot of people, pretty opaque. It makes white lines on radiographs, and we can get paid by the insurance company. But endodontics is much more than that.
So, you might ask yourself, ‘Well, what about the single-cone technique?’ That’s a whole conversation. And then, you might ask yourself, ‘Well, what about the bioceramic sealers?’ And there’s a whole class of ‘em that are available by different companies, as I’ve mentioned. So, essentially, if we’re gonna do a single-cone technique, many people that do it call it a hydraulic technique, and really, this is misinformation. There’s nothing hydraulic about a single cone, but what they really mean, what should actually [laughs] really be clarified, it’s called hydraulic material because it requires moisture to set up and become hard.
So, we all learned that in the early days, with MTA. We would always have moisture. The moisture requirement was fulfilled on the apical side, because of the periodontal attachment apparatus. And then, of course, on the inside we’d oftentimes put a wet cotton pellet, certainly a very moist one, against the material coronally. And the moisture, then, would allow the material to set up. So, that’s something to think about, because let’s not construe whatsoever that a hydraulic material that requires moisture is a hydraulic obturation method. Completely different concepts. Okay.
Do we have to worry about our reagents, and will they affect a bioceramic cement? They’re not really affecting the more time-honored, Grossman-type sealers or even some of the other sealers that have come along in recent years. We have things, examples like AH Plus. It’s a resin-type sealer. But those sealers really behave pretty well with the adjunct of sodium hypochlorite, EDTA to remove the smear layer, and then the EDTA opens up the lateral anatomy. So, when we reirrigate with sodium hypochlorite, we can get better penetration of Clorox into the tubules and the lateral anatomy, where it can circulate, penetrate, and digest tissue. So, the regimen of sodium hypochlorite, EDTA, sodium hypochlorite has worked well in the traditional obturation methods and sealers.
Then came bioceramics. So, your bioceramic sealers are definitely sensitive to residues of sodium hypochlorite or EDTA. So, it’s been advocated, the final rinse should be saline, buffered saline, or what’s called phosphate-buffered solutions. Now, these PBS’s are interesting to use, but they also have their problems. It’s been shown in the literature that PBS begins to lower the acidity from the bioceramic sealers, and they have found microbial growth in dentinal tubules. So, when you see that, then you start wondering, well, what else is happening? So, we have a problem in that we want to use, I would think, a material, a solid-core material, it could be gutta-percha, that can be molded with heat. It can be a heavy-body material that drives the sealer, light-body material, into all aspects of the root-canal system.
So, to do that, that would be either a carrier-based obturator or some form of warm gutta-percha. So, now, back to single cone, canals are never round. Their cross- sections aren’t round. There’s a plethora of anatomy. There’s open dentinal tubules, if they’ve been disinfected and cleaned. So, what can we use to fill root-canal systems and do a good job? And my problem with single cone is, the cone is cold, and in no manner, shape, or form is it really developing hydraulics. In fact, when you put these cones in, oftentimes you’ll see venting, and a lot of your sealer, if not most of it, ends up in the pulp chamber.
So, you’re not capturing waves of condensation to effectively drive that sealer under enormous pounds per square inch into all aspects of the root-canal system. So, I’d like to look at my notes. I prepared a few little notes here. If you live in China or Asia, you’re getting iRoot SP. These are brand names of bioceramic sealers. In North America, Brasseler sells EndoSequence BC Sealer. Europe, FKG, the company, sells TotalFill BC Sealer. And worldwide, Edge Endo sells EdgeBC Sealer. These all have their formulations and their differences, but they’re basically, again – they’re a tricalcium, silicate-based material. And they’re very sensitive in final rinse solutions or any reagents that are used in the canals themselves.
So, when you think about portals of exit, cul-de-sacs, root-canal systems, when you think about everything we’re trying to seal, from the work that you can see through radiographs or the model of the animation, the assignment is a little bit more than a single cone. Let’s talk, though, about single cone. In single cone, and if we’re gonna use a BC sealer, because it seems to go hand in hand, the people that are doing this have minimal preparations, and minimally invasive endodontics has driven an awful lot of the single-cone idea, because the armamentarium just doesn’t fit. It doesn’t – it can’t be introduced in these much smaller, more conservative preparations.
So, single cone has kinda become popular. It’s like in vogue. It’s like a fad. So, single cone. You’re gonna need to use some kind of a buffered solution. But again, be careful what you’re using, because it even has effects, and I mentioned the microbial activity in dentinal tubules post-obturation. That’s been documented. Also, if we’re gonna use warm gutta-percha, we’re gonna plunge in with heat. Even though there has been, quote, formulations designed to use warm gutta-percha, let’s remember the moisture requirement. When you plunge a hot instrument into a material, you are going to evaporate moisture. You’re going to change its chemistry. You’re going to change its formulation.
And what you’re dealing with isn’t actually the BC sealer that you started off with. So, that needs to be considered carefully. And of course, a lot of work’s being done around the world studying that, right now, as we speak. I wanna also make another critical distinction. Bioceramics are fabulous repair materials. Did you hear me say, ‘repair’? Root end, lateral repairs from perforations, iatrogenic or pathologic in origin, and because of the chemistry in the material, it’s been shown to induce bone formation. And if it has calcium phosphate in it, it’s going to even be a bone precursor and a scaffolding for bone to be deposited on. So, very, very good as a repair material.
But today we’re not talking about a repair material. We’re talking about a sealer. So, I mentioned heat, and heat’s a problem. If you use a single cone, you’re gonna end up with pools or lakes of cement. And of course, when you have lakes and pools of cement, you probably wanna know, does the material wash out? It's been shown that it does wash out, because when sealers get into spaces that have body fluids, okay, like in the canals, parts we can’t dry, think of the lateral anatomy, the tubules and all that, it does affect the chemistry. And that means the actual properties of the material, as it sets up over time.
So, just like in the animation that was modeled off of a real human tooth, where we saw evidence of the ubiquity of lateral canals, loops, fins, cul-de-sacs, multiple portals of exit, you can see in our clinical cases, we see good evidence. And of course, to fill root-canal systems, it requires some hydraulics. And I’m not gonna get into how to fill using vertical condensation or carrier-based obturation today, but I think everybody begins to realize that if you can thermosoften your core material, gutta-percha, and if you can put loads on it, whether it’s a carrier inside an obturator, or whether it’s a plugger on warm gutta-percha, you build enormous hydraulics.
And you can fill into all aspects of the root-canal system, the caveat being, if you have first cleaned and eliminated tissue. Remember Newton’s laws of physics, ‘Only one mass can occupy the same space at the same time.’ So, be very aware of your chemistry. Be aware of heat. And on the pools of cement, that can wash out, and we have literature that shows that in simulated body fluids, it does wash out. So, I notice on the websites, the people are doing GentleWave, sometimes they’re saying, ‘Well, we didn’t even find the canal, but we filled it. We’re really excited about that.’ Or ‘We couldn’t get to end. We couldn’t get – negotiate the canal to the terminus. And we’re really – we were very disappointed about that. But when we filled, we could see sealer going down into these places, and it appears radiographically [claps hands]. We did a pretty good job.’
Be aware of the simulated body fluid studies and the wash-out and be aware of that. That’ something to be aware of, because there is solubility. BC sealers are soluble. It’s hard to quantify how soluble they are, because nothing’s ever in the ISO standards. In the ISO standards, they use water, okay? That’s how they check solubility of any given material. But the problem is, water isn’t necessarily what we’re dealing with, with residual moistures inside a vascular root-canal system. It could be simulated body fluids that are studied in the laboratory, or it could be actual body fluids that we’d find inside a tooth.
Probably most importantly, I’d like to just mention, everything can fail. I’m really serious now. I spent most of my career, well over 40 years, re-treating other people’s work. Over 90 percent of the patients that arrived to see Cliff Ruddle had already had endodontics, and oftentimes, sometimes, surgery as well. And I was doing non-surgical re-treatment and surgical root-canal treatment. What’s my point? This sealer does not fulfill Grossman’s criteria for an ideal sealer, and we all have read those long list of things. You know, ‘Won’t stain the tooth’, but one of ‘em was, ‘It should be easily removable in the re-treatment situation.’
Currently, there is no chemistry that can dissolve a bioceramic cement. There is nothing that’s – that they’re miscible in. So, there’s no chemistry to help us dissolve this material from the eccentricities off the rounder parts of shaped canals. And then, mechanical. The single cone has been touted as, ‘Well, you got a cone in there, Ruddle, so you can just simply use obturation removal ideas, and you can auger out that gutta-percha. That’ll give you a pilot hole back to length, so you can get the rest of the sealer out.’
Well, I saw this done recently by a Brasseler guy. I won’t mention his name. And he was doing it on a plastic block, and he was sayin’, ‘Look how easy it is to get this out, because some gurus say you can’t get it out.’ Wait a minute! A plastic [laughs] block is a round canal. It was a little tiny curve in the canal, and he showed running down through the BC sealer, augering out the gutta-percha. And he says, ‘There you go.’ Well, try doing that and looking at it in SEM, on real teeth. How about a little study, because we’ve done this, where you can basically fill a tooth, you can section it after you removed it, and it’ll be loaded with residual sealer that couldn’t be removed mechanically, with instruments.
So, there’s no way to remove the material mechanically or with chemicals, and that should be a bit wake-up call, because you’re putting it in people’s mouth, on a routine basis. You’re hoping your single cone works, and we don’t have the protocols internationally on irrigation, to give everybody this newfound confidence, okay? We have things coming. GentleWave is interesting, but we really don’t have good cleaning protocols that are being used by the masses. But yet the masses are using single cone, and now, a lot of ‘em are using it with bioceramics.
Is there anything else on my mind? Actually, there are more things on my mind, but I’d like to mention that we don’t have long-term follow-up. Okay? I mentioned we don’t have ways to remove it, but we also don’t have long-term follow-up studies that look at these cases at 5, 10, and 15 years. So, before we jump from what we’re already doing and probably were doing pretty well and had good results, if you were cleaning and shaping properly, and the sealer was working perfectly for you, why would we change just for the sake of change? We should really only change to a new sealer or a new whatever, if there’s evidence to support it, and it’s readily reversible.
Because, in life, as it is [laughs] in endodontics, things happen. And we have to be able to have reversible ideas, so we can get back in there, disassemble teeth, reclean, shape, and pack ‘em, so that they can be properly restored and go on and give the patient a lot of years of good service. So, my comments on single cone, it’s probably a cold cone. It’s not going to adapt well to the complexity of the root-canal system, and the bioceramic sealers, to me, are not reversible. And that disqualifies them, in my world, as an endodontic sealer. But I think they could be used as a good external repair material, or an internal repair material, in the cases of pathologic or iatrogenic mishaps.
CLOSE: Superlatives – Best & Worst
Okay. So, we’re gonna close our show today with a segment we call Superlatives, and that’s just the best and the worst. So, I’m gonna ask him some questions, and he’s gonna give us answers.
Best article you read, in the last year.
The article by Mario Alovisi and Elio Berutti, and it was called “The Influence of Contracted Endodontic Access Cavities on Root Canal Geometry”. That was a fabulous article, because it went to show that we can make smaller access cavities, but in life there’s the yin and the yang. There’s the good news-bad news. The good news is you have maybe a little stronger tooth. The bad news is, they showed a lot more procedural errors, when you were trying to work through a small access window. So, I liked that article.
Worst article you read this year. And you don’t have to say maybe who it was by, but you can maybe say what it was about. [laughs]
There’s actually quite a few articles I’m not fond of, and it has nothing to do with if it’s commercially driven or might compete against a product I invented. It’s not that, at all. We have a lot of really mediocre articles. I’m actually shocked that sometimes they get into peer-reviewed journals. I expect that in a trade journal. Come on, please. No peer review, just submit it, and pretty much rubber stamped, in it goes. But I’m talking peer reviewed, and we have just endless amounts of – leakage studies are so riveting [spoken while yawning]. They’re so exciting for me.
But I really did think that we could take all the bad articles and put them all together and start a new journal, called “The Journal of Retractions”.
Best case you saw last year was done in what country?
Well, I’ve seen a lot of great cases this year, because as you know, you’re on the front lines at the office. But they come in from all over the world. But I would say, Roberto De Castro, from Belo Horizonte, in Brazil, sent me a maxillary lateral incisor that went up about 12 millimeters. Then it made a dogleg, and it went for like another six or seven millimeters, and it was in exquisite shape. The obturation was thrilling. I remember that one, still. And then, Reid Pullen, Southern California, great endodontist, shaped a case with ProTaper, and used GentleWave and showed an amazing array of anatomy. And it kinda looked like Hess-type stuff. So, Reid, Brazil [laughs], Roberto.
You guys, best case I saw this year, yeah.
Okay. Best new technology in the last couple years.
GentleWave. Okay. Best, because GentleWave, once you pay 70 grand and throw away your handpiece for 100, and get that platform and get that seal, I mean, we’re seeing some pretty exciting cleaning. So, a lot of people, I’m not being cynical, many of us have been filling in the root-canal systems for decades, but it’s allowing more people – apparently a new wave of endodontists that now have finally discovered anatomy. It’s allowing them to clean root-canal systems more effectively.
Okay. Great. And now, the worst new technology in the last couple years.
[laughs] Good and bad. Well, what’s the bad news? They need to perfect the protocol. Case selections needs to be reviewed. Post-operative pain is exaggerated. Sometimes they don’t have the right shape, oftentimes, because it’s a minimally invasive concept. So, we have parallel apical thirds. That means it’s a two-way employer opportunity, where irrigants can go out and come back, so we can pump irrigants through the foramen and needlessly provoke post-op pain. There’s bleeding incidences. So, bleeding, post-op pain, cost, platform time, it has made for a lot of negativity in the marketplace. But the potential upside could be quite amazing.
Okay. Best question you received in a lecture last year.
Yes! It was Amman, Jordan. And it was Dr., Professor Edwin Quoies [sounds like]. We were in Amman, Jordan. I had just finished an all-day lecture, and there was about 12 of us. I don’t think we were the 12 disciples, but we were thinking we might be 12 endodontic disciples. We were sitting around a big table. We pushed back after dinner, and we talked well into the night. And Edwin turned to me at one point, and he said, ‘Cliff, when does endodontics truly begin?’ Well, you know, I started to --
I think we’re gonna have to save that answer, maybe for another show.
But that was --
That was a Zen type. That’s very provocative, yeah.
-- [laughs] a – worst question you received recently, in a lecture.
Oh. You know, we always say [laughs], as teachers, ‘There are no bad questions.’ Believe me, there’s some really bad questions.
But we wanna be uplifting and put our arms around people and grow people, make them all they can be, more than they were, certainly. But anyway, the worst questions are primarily when somebody gets up and starts to pontificate, and it’s – I’m listening for the question, but I realize it’s a long dissertation about ideals and philosophical feelings and how they approach their work. And sometimes, when they’re all done, I go, ‘Well, I didn’t hear the question, but it was very nice what you said to the audience.’
So, there’s that kind of a question. And then, there’s the people that aren’t listening, in lectures. I mean, you see them on their machines, and all of a sudden, it’s like, they have this question. They’re like really – ‘Yeah. I got a burning question!’ You just like look right over ‘em, you don’t even see ‘em, and finally, you can’t ignore ‘em, because these are very tenacious people. And they’ll come right back and so, they’ll say something that you had just answered to the entire audience, and the whole room looks at him and going, ‘Where were you? Show up, please!’
‘Be present!’ So, there’s those kinds of things.
Best advice you heard this – in the past year.
Well, the best advice I heard this year has to do with people that I lost through death, in this least year. And I remember very clearly my dad’s comment, ‘Plan for the future, but live every day as if it were your last.’ So, that’s pretty good advice, because nobody promised you tomorrow. So, like, have a lot of fun today. Get it done. Kick some [bleep].
Carpe diem, basically?
Yeah. Seize the day. Absolutely.
[laughs] And worst advice you heard this year.
Oh [laughs], geez, worst advice. How much time did you say we have?
Well, you know, there’s different websites and platforms, and there’s some people that come from knowledge, and their truth is the truth, and nothing else is there room for discussion. And there is an arrogance about it, because really, if you are so convinced of your truth, you should be able to share it. You should be able to be wrong. Your greatest growth in life is when you can say, ‘I might not know this. I might need to just listen a little bit and get a different perspective.’ But when I start to hear that some of us don’t understand the disease model, that’s pretty – that’s pretty arrogant. And then, what was the other buzz word that they like to say, these three people? They’re not the three Wise Men. I mean, we’re – we have Christmases that come and go, but these are not the Wise Men. These are three endodontists that are quite angry. And they wanna talk about the process. So, a lot of us are just process endodontists, you know, we anesthetize – no, we select the right tooth through diagnostics, we anesthetize, we isolate, we negotiate, we prepare, we disinfect, we fill root-canal systems, and we restore, some we restore. So, they say, ‘That’s a process’, and we’re all caught up in process. From what I can tell, if we’re going to the moon, there’s a process. If we’re gonna build a tower, you know, and it’s Dubai, and we’re gonna go up that high, we have to – there’s a process in how things have to unfold and engineering and stuff. So, most of life – neurosurgery, it’s a process. So, I hear that we’re process oriented. No, we do procedural steps that have been shown over the last 50 to 60 years, make sick people well. So, that’s --
So, their advice is, ‘Don’t focus on the process, focus on’ --
-- well, they would say, ‘the patient’. But, I mean, come on. Everything we do is patient centered.
-- [laughs] the patient’s part of the process [laughs].
They certainly are! So, yeah. You get a lot of people that come from carnal knowledge, and they’re – there’s the – they’re the truth, and us mere mortals are dancing around, hoping to catch it someday. [Background music]
So, vague advice [laughs].
Okay. Well, that’s our show for today. Hope you liked it. See you next time, on The7 Ruddle Show. [Music playing]
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