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…It would be just like a clinician out there, taking their mouth mirror and doing all the little tap-tap-tap on the teeth… Oh, ouch! —

— Oh gosh!...

Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle.

How you doing today?

Pretty good. What about you?

Well, I’m really looking forward to this first little segment, because it’s already feeling a little awkward.

Yes, we’re going to talk a little bit about social skills. So we all have moments where we’re social awkward. Sometimes when it’s happening you might just feel like you want to run away it’s so uncomfortable. But then a lot of times when you look back on these situations, they can be actually a little bit funny.

So some examples of social awkwardness could be you’re talking to a group of people and you have food in your teeth and no one says anything. Or maybe you tell a joke that is completely inappropriate for your audience and no one laughs. Or maybe you have a small child with you that asks strangers really embarrassing questions. I give these examples because they have all happened to me on numerous occasions. So if we ever decide to do future segments of social awkwardness, we’ll have lots of material.

We’re packed then.

So the scenario for today is this. Someone recognizes you but you don’t recognize them. What do you do? Has this ever happened to you?

Never.

Really?

Yeah, it happens more than I’d like to admit. I guess I’ll give a context so you don’t think I’ve lost my marbles. But anyway, it would be something like this. So I’m lecturing all day long – let’s just make that up, because it’s happened a thousand times. And finally at the end of the day, or mid-morning break or lunch time, mid-afternoon, somebody will come up to me – and I should say I never forget a face. I have almost like a photographic memory on faces, but I am horrible on names. So they’ll come up and they’ll start talking to me like we’re old friends, and I have no idea who they are. So that can be a little bit awkward and I usually play along with it.

And then the other thing; Phyllis is my secret weapon. She oftentimes can remember who they are in the context. The context is everything. Do I know this person because they came to Santa Barbara? Do I know this person because I saw them at a previous lecture on the road? Do I know this person from phone calls, email exchanges, etc.? I don’t remember the context.

So I guess I’ll say this in closing of my little piece. It’s really helpful when somebody runs up to you and goes Cliff! Glad to meet you! How are you today? You might not remember me; I’m from Texas. Okay, we’re rolling!

So that’s your preferred way for people to approach you?

Yeah, because they shouldn’t expect because they’ve been there in the lecture all day and they might be one of 800 people in the crowd. They really connected with me; they’ve been watching me all day long. But they’re a single face in the crowd and maybe I didn’t even see them.

Okay. Well I’m not as famous as you are, but people do tend to recognize me. I think it’s because I have sort of a circus look going on. But anyway, like you have mom, I have my daughter Eva. And she throughout her – like she’s now 23 – well her whole life she’s helped me out. So we’ll be somewhere and she has – she’s always looking at her surroundings and I have very tunnel vision.

She’s an observer.

Right. So she’ll notice someone and she’ll go Mom; over there is Becky. Remember? You know her from baseball. Her kids are Jacob and Lauren. And then I’ll go okay, thanks. And then a little bit later Becky will come up to me and then I appear very knowledgeable.

So sometimes when Eva is not with me though, someone will come up to me and start talking to me and immediately I feel so panicked inside if I can’t recognize them. I’m trying to listen to what they’re saying, but at the same time in my head I’m having a whole other conversation of where I might know them from. Like you said, context is everything, and I’m seeing them obviously out of context. And then I start thinking, I wonder if they can tell by my eyes that I’m being too shifty and I don’t recognize them. So it just gets very difficult with all the conversations going on externally and internally.

Two parallel conversations. Who is this person and how do I know them? And then what are they telling me right now in the moment? So lets not let our forgetfulness sabotage our ability to reconnect or connect. Because you know what? They’re happy to see us and you’re happy to see them and vice versa. So as I get older, I’m not so proud about it anymore and I’ll just say who the Hell are you?

Well some advice I heard that I actually thought was really good is that you’re never supposed to say, “Nice to meet you,” because that’s a dead giveaway that you don’t remember ever meeting them before. So it’s better to say, “Nice to see you,” because that -

So photographic memory with faces; it would be good to say, “Great to see you again.” And I actually do say that a lot. And that puts them at ease and they think I know perfectly who they are and we’re rolling.

The last one I’ll say that’s the worst is I’m talking to somebody; I don’t know their name, but I know them. And now three more friends walk up. And let’s just say for fun, I know them, but I don’t know their names either. So I’m sort of – maybe it’s not my job, but maybe I was anointed to be the introducer. So I usually just play it like this: gosh, you guys are all so famous. Why don’t you introduce yourselves because I don’t think we all know each other. So then everybody just says well I’m Harry; I’m from Brazil. I’m so-and-so, I’m from Italy. Okay, that helps.

Okay. So hopefully you all don’t have this problem too often. But if you do, just try to have a sense of humor about it. It’s not the end of the world to say just remind me of your name.

Okay, well we have a great show today, including What Phyllis Thinks. So for all our Phyllis fans out there, please stay tuned for that. But let’s get going on it.

Well it’s really great to be back at the board and have a little opportunity to learn together about endodontics.

Listen. I took a lot of – I won’t use my normal language because that would not be appropriate, but I took a lot of flak from my team about this title. They were saying well what would an endodontist say? What would the AAE say? Well they would say just what they said in the ‘70s when I got disemboweled and almost killed because I was teaching general dentists how to do root canals. That’s what they would say.

So seriously, this is an exciting topic. I want to tell you that this is really just a fast paced, photo reveal of start to finish endodontics. I want you as a general dentist or an endodontist just to look at the work. There’ll be no x-rays; how about that? A surgery lecture with no x-rays! This is a photo, fast paced delivery of how it should look if you’re going to be successful.

Now listen. If you’re a general dentist out there and you’ve been out for 10-15 years, and you’re pretty well trained in a variety of multi-disciplinary treatment approaches, do you think you’re not capable of lifting a three-tooth flap in this region right here, maxillary anteriors, and helping a lot of your patients out? Do we not have many dentists that practice great distances from endodontists? Do we have endodontists that don’t feel comfortable doing surgery? Do we have endodontists referring people to oral surgeons to do surgery? All this is true and more.

So I don’t want to get into a morality/ethical thing. I’m a teacher and I’ll teach you everything I do. If you don’t want to it, you don’t have to do it. But you should know how I’m doing things, because if you sit out there in a big metropolitan area and you’re in a multi-disciplinary study club, and you have different people coming in – treatment plan for what’s best for the patients – you need to know what’s available to best serve your patients.

So whether you never do surgery, you do an occasional simple, single-rooted, anterior maxillary tooth – listen to those qualifiers – did you ever think that you might graduate to one down here? You might get a canine; you might move to a bicuspid; crawl, walk, run.

So anyway, enough has been said; let’s look at some photos. And I think you’ll get pretty excited, because if you can see it like this, you should be left with the concept of if I can see it like Ruddle, I could do it too. Well, let’s take a look.

So you’re going to have a team. I’m almost always just one assistant in the operatory for clean, shape, pack; for diagnostics, trauma, all of that stuff. Retreatment: one assistant in the operatory. We have a rover come around and help us if we need it. Surgery, you’re going to have two dedicated, scrubbed in personnel besides you, making a three-man team; and that means you’re going to be able to address everything to serve the patient.

So we have people in here; we’re using a microscope. This is one of my first microscopes way back in the early ‘90s with the observer tube. I don’t really even use the observer tube anymore because the assistant likes to look at monitor. When you lock somebody down on an observer tube, all of sudden you’ve taken them out of the action except they’re a professional sucker and sprayer. So if you want that assistant to be a little more multi-dimensional, then we want a monitor. And there’s monitors on all the walls, monitors on ceilings; you can see things and then you’re in the game. So the surgical team needs training, and that would be probably the biggest thing to pass on here is train.

Okay. So you won’t be doing this one for your first surgery because you’re looking at it; it’s a mandibular bicuspid. There’s a broken instrument that screwed in; it probably over engaged and it taper locked, right out the end of the foramen; it’s long. So you see there’s a casting on the tooth, probably one of those zirconia crowns. You’ve got a well-placed post, it’s engaged, it’s an active post, it’s a threaded post. And you’re probably thinking oh geez; he didn’t even mention the middle foramen and the neurovascular bundle. So what about that? So that’s probably one you would like to know; it can be done, but it’s not in my best interests to do it. Somebody else will do it.

So when you talk to the people that do do it, we would frequently want to have prep control. We wouldn’t want to have a lot of bleeding. You can start to see some of the ideas here. Look at how well I can see it. You would probably say well gee; I can do that too. But you have to get there and that’s a bunch of little procedures that we’re going to talk about. So this is just to get started.

So when you see instruments that are long – sometimes you can push them back up and out, but I’ve already talked about bring the patient into it. What does the patient want, what is best for the patient? We’ve talked about in many shows how you can inadvertently or overtly drive that conversation and get people pretty much to do what you want to do. So be honest, be ethical, and the question would be what would you do if it were on you?

And when we get this done, we can learn to bevel. We can bevel at lots of different angles; in this case we’re beveling like this. We want to keep as much root as we can. If you start to bevel like this, you’re going to get a shorter root. But the facial part of that bevel – the facial part of that bevel needs to be observable from the operator’s standpoint because that’s how we can do the retro prep and do it very exquisitely. We can do our acid etching and we can do our retro fills and we can suture and all that’s going to go well. So each step is managed so we can take the next step. And by taking a series of sequential steps, we can get to the outcome that we’re looking for.

We can operate around the neurovascular bundle, we can see healing on recalls, we can get PDLs to crawl back around that apisected root, and that is bread and butter, start to finish surgery in one slide. But now let’s go very rapidly.

So I’m going to start off with your flaps. In a previous Ruddle Show, I identified the three flaps, so I won’t speak more about it except to say in a full thickness flap, you’re going right to the sulcus. The blade is pretty much parallel with the long axis of the tooth and you’re going right to bone. You’re going right to bone and right through the periosteum.

And if you go in here and you look at what the assignment is, you can see that there’s been a transportation. The physiologic foramen would have been here, your first file would have gone around the curve and ended somewhere right in here. But bigger and stiffer files have ripped the foramen to a new manmade location on that apisected root, and you’ve got to get that out of there. That’s dead space, that’s microbes; that’s infection. So that’s a little bit about we want to do that; we want to see it. So the granulation tissue is all around the end of these roots frequently. It’s either a cyst or it’s granulomas, and biopsies will disclose that.

Now on the incisions, measure twice, you can cut once. Use microblades. Be very clear what you’re doing. These vertical incisions must fall in between the teeth. They must be pretty much up and down. We don’t make oblique releases because the vasculature runs parallel to the incision; so we don’t want to cut across the vessels, we want to cut with the vessels. That’s just a little trick. And you come right down, and if you plan ahead, CL suture before you cut. Measure twice; you can cut once. Already see the suture in your mind. So do you keep the papilla or do you take the papilla?

Now we’re going to use a 15C microblade, and we’re going to hold it pretty much parallel to the long axis of the root. And you can see, we’re going to go in that sulcus and scallop around and scallop around. And you can see that’s a very small blade; you can follow the contours, the morphological flow of that external cavil surface of that enamel crown, and you’re going to get very, very nice, clean incisions. And if you do that, already you’re having more confidence. When you do things wrong, your incision is wrong, you’ve made your vertical release oblique instead of vertical, bleeding starts to happen, you’re tearing tissue; be careful.

And we talked about the submarginal flap, also called the attached gingival flap. But if you have a big band of attached gingiva, the only request is go down below the attachment. So if you put a probe in here and you’re measuring probe depth, you might probe to here and you might probe, okay. But you have to go about 2mm apical to the attachment – to the attachment. And then if you have more attached gingiva, perfect. And again, notice how we’re scalloped, we’re scalloped. Well, we scallop our incision. So when we’re all done, this goes back together like gears and you can reapproximate and reposition very quickly. So plan your incision.

And of course elevation comes to mind. These were named after me, the Ruddle Elevators, by Dr. Gary Carr in San Diego. That was nice of him. But they’re small, they’re contoured, they’re convex around the end. But the idea is do an undermining incision where you start up in your vertical release, and then you start coming down. And that’s an undermining incision. If you go in here in your incision and try to get that instrument, you’ll crush this side of the flap. You’ll crush this and you’ll get a lot of bruising, a lot of swelling, and a lot of needless post-operative pain. So do an undermining incision.

And you can see it coming up. Now that you have that corner of that flap up, you can just come around, always working superior/inferior and undermine and elevate, undermine and elevate, and there it is. So those are little ideas.

So far we didn’t talk about it, but we will in the future. There’s going to be a whole platform around surgery. So guess what? Good anesthesia. Measure twice; you can cut once. Choose your flap. Think it all through; see it sutured before you cut.

Well the next thing is you’ve got your flap up and you’ve got your retractor in there, and you might get that soft tooth distal end in the retractor so it can really grab that bone and not slide around inadvertently. And of course you’re holding the flap up. So rest on bone, not on soft tissue; more bruising, more post-op swelling and pain if you’re resting on tissue.

And you can begin to see to do an osteotomy and we have to make a window. Now sometimes this is already perforated, and sometimes it’s just a matter of going in and starting the cleanup. But once you get that window off, or you got it cleaned up, or it wasn’t even there – there was no bone; it was fenestrated – then we want to get in here and do our curettage, and we can begin to scoop out these lesions, drop them into a test tube bottle for biopsy – off they go to the University of California San Francisco as an example – and you can get a biopsy report of what it was. And remember the old lecture, Dr. Landwehr; anything can happen to anyone at any time. So you’ve got to be sure you know what you’re dealing with and don’t get surprised. So that can get scooped out.

Well then you have your apicoectomy. So you’ve got the thing enucleated, it’s cleaned out, and you can use a big surgical length tapered diamond, I guess by Dentsply; they’re the only ones that make that extra long grid. It can do deep into the field, bevel across even and MB root of an upper molar – it’s a big, broad root, facial lingual. So you need length and it’s diamond. And you get a nice, flat point. Now the bevel could be like this, it could be like this, it could be like that, it could be turned away. But the bevel usually faces the operator for visibility purposes.

And we’ll keep going. But you’re saying but Cliff; it looks so easy, but it’s bleeding! When I lay flaps, my patients have blood! Well my god, there’s no blood in Santa Barbarians; that’s why I do surgery. Listen! You need to know how to control the bleeding. If you could see it like this you’d probably even do a molar. Look at this molar. You can see this resected root; see it swinging around, like a kidney bean. Whoa! I see gutta-percha! Oh, I see another foramen; a missed foramen! Oh, I’ve got to announce – look at this. Figure 8, look at that. Flat bevel, see it perfectly. You want it flat so when the light refracts off of the apisected root, you don’t get a lot of scatter. Light scatter is going to give you like moguls when you’re skiing; you can’t see so well, right, so you want it flat. So that’s what you want.

Then you can come in here and use something like a ferric sulfate. I won’t balance the formula today unless you ask me to; how about that? So ferric sulfate can be used in all of its various iterations commercially. You pull it up in a syringe, it’s a brownish solution, and you wet. You wet. Oh, that’s not going to work. I want you to wet the bristles. Notice I don’t want you to go into the field like this. Because instincts are with a lot of laymen, you’re new, you’re nervous, you’re a little anxious. Awkward, we’ve talked about awkward, we had to pull the color out of awkward, a little hot. If you hold it like a pencil you can’t cement any more reagent. So out in the field, push a little bit on the plunger, wet the bristles – they’ll turn brown – then hold it like a pencil and you can scrub; you can scrub. And every time you see a big black are in here, that is the coagulum; the residual biproduct from shutting down the bleeding. So now you can see.

So you don’t want to get this on the flap; you don’t want to get it on the mesial aspect of the flap because it causes tremendous vaso shutdown. It shuts off blood supply and you could have a flap slough. And when we’re done, we’re going to curette the Hell out of that to stimulate fresh bleeding before we do closure. Let’s keep rolling.

Well the game changed when Gary Carr invented root end microsonic instruments. I say microsonics because they’re bolted into an endodontic ultrasonic handpiece, and you use the microscope in conjunction with the ultrasonics and that’s microscopic root end preparation. And unlike the old way with the slow speed and stuff, these can go because of their configuration right up a long axis. You can get these in 3mm lengths or in 5mm lengths, and that just depends on how much dead space up in the canal you want to eliminate. So you can go up 3mm or 5mm.

So now you’re starting to say you know, I don’t do these very often, but now I’m starting to appreciate what my endodontist down the street does. If you don’t have an endodontist down the street, you’re going well, I’m going to have to take some more courses, but certainly I can start doing some simple ones. You can do it! How do you think I did my first surgery? You know what? I did three surgeries in Boston at Harvard School of Dental Medicine as a resident. So where do you think I learned all my surgery? After I got out.

Well, when you’re using ultrasonic energy, the biproduct is heat. So if you’re going up a tooth that’s been filled, a canal filled gutta-percha method, then you should see streaming and the gutta-percha should be coming out of this canal as you create heat. And so you prep it up, get it all out; we had little mirrors that we borrowed from medicine back in that day, and these mirrors are different sizes and configurations, and we can look up into that retro-prep and there’s the mirror shot. And you can see we’re up about 3mm; I’ve used little micro-pluggers and flattened off my gutta-percha – pack, pack, pack – to step it around the circumference, pack it up level, and you can inspect it. You can inspect your prep, because you could see sometimes a little gutta-percha in here, and if you do, scrape it off; scrape it off.

All right. Well, I don’t know what you’re using to fill the end of the roots, but everybody‘s method, whether you’re using amalgam, super EBA, MTA, whether you’re using Biodent, whether you’re using ceramics, whatever you’re using it all benefits from this. Because you’re using 36% phosphoric acid gel. And you can see it has enough viscosity that you can squirt it in a very controlled method right into your retro-prep, and you let it sit there for 15, 20, 30 seconds max, max 30 seconds. And that is going to clean off the smear layer, it’s going to roughen the surface because of the acidic reaction, and you’re going to have more surface area, you’re going to get a better, tighter seal. Yes. I think I can do one now almost.

You can dry in with taper points; we used to. That retro-prep can be dried a lot of different ways. But you can also get a Stropko – we’ve talked about Stropko several times. Whoa John! Are you out there? John is about 100 years old and he’s still teaching, so I was very excited to get a recent email from him telling me that he’s back to teaching and he always was a teacher. So there’s the Stropko, that’s this device right here. It goes in your syringe. And then there’s a variety of lower lock thread cannula that go on this, and you can bend these in a nice, rolled radius so you can put them right in the prep – right in the prep – and ch-ch-ch.

I should add I have a Chapman-Huffman valve, and air regulator control, so I’ve reduced the air pressure to about 7, 8, or 9 PSI (pounds per square inch) for international.

And I’m almost done. So just coming back to this tooth, we have a nice crypt, you can see it all cut out. We’ll have to have Niemczyk, Dr. Niemczyk, one of the best surgeons on the planet, talked to us about that Piezotome and getting that saw in there and cutting the plate out, putting it in water. And then when you’re finished, put the plate back – but that’s more advanced. But just simple kinds of preps. Are you starting to notice the way the preps are prepared and the isthmus are following the configuration of the roots? The internal anatomy is a perfect mirror of the external anatomy, especially at beveled, apisected roots.

And my producer will love this as I zoom in. We did that in post, so you can see a little bit more. The image starts to break down when it gets this big – you can see a little artifacting in here – but you’re getting an idea of how precise and how clean and how much visibility we have. That’s what I want to leave you with. That’s why I keep saying you can do it. No, you’re not going to start on a molar. I don’t think you’ll say the first one will be the palatal root of the second molar. I don’t think so. But if you did, I would think it was a very nice joke.

And the last case then is just real quick. So you pulled up a flap, you thought about this, you’re trying to save a molar. You know some of these roots on the molars, you can palpate them and feel them, and they’re almost closer to the surface than the anteriors. Now that MB root is broader, as we’ll take a look. So you scoop out the granulomas tissue, this is all cleaned out; and now you have a crypt, you’re looking in; you did your curettage, you flattened out your roots, you can see a little streaming there. But look at that! Is that not like a nice thing? It’s not nice because Ruddle did it; it’s just nice because what? I can see it; I’ve left a nice band, a nice collar of bone so I don’t get an endo-perio problem. I got all the way across that root; you can see it back in here and it’s around like that. But look at the external concavity is reflected by the isthmus; the isthmus was run out with ultrasonics, total control. So that’s what I want you to think.

And then finally we’ve got to get it down and get it bolted together. So how do we do that? I think you just walk out of the room because it’s your first surgery and you need a cup of coffee, and you just say to your assistant: Close! Well they’ve never closed, so I guess it’s up to you so here’s the close.

So you start to put the flap back down, okay, you know that. And that’s called repositioning. And then of course just like gears, like this tissue here, it’s going to match up, going to match up, going to match up because you planned all of this. And so there’s the first thing that we do is we suture.

Now a lot of these stop right here, but if you notice – okay, there’s different cables, there’s multifilament, there’s monofilament, all this will be discussed. This is a mono filament. But you’ll notice, when you tie your knot, we’ll always be exactly right on top of the incision. And of course these knots – even if it’s monofilament – they’re going to trap food, and that means bacteria, and that’s going to make the wound hesitate to heal if it’s inflamed and there’s inflammation from all that stuff. So good surgeons know – I learned this decades ago – grab the knot and pull down. And now you have a single filament – a single filament coming across that incision site.

We used to take sutures out at 10 days in the ‘70s. Then we took them out in one week in the ‘80s, until 86 and 87, and then we started taking them out with a microscope at 48 hours. So all sutures from Ruddle came out in 48 hours, because the tissue is already attached; there’s nothing more that the sutures are doing at this point except causing inflammation and discomfort.

So if you do all this, you can get to the 30-day check. I didn’t show you the one-week check; the 30-day check is what you’re looking at. You can’t even tell where we did surgery. You can’t even tell.

So in the future. Today we marched a little bit rapidly through flap design, osteotomy, curettage, apicoectomy and radicular prep and closure. But I have a lot more to give you. I have 20-25 hours right in here that would really help you start to think I can do that first one right here.

We’ll use these principles and come over here. This means surgical access to posterior roots, lateral repairs, exploratory surgery, orthograde surgery. We’ll be looking at surgical failures, because a lot of surgical failures got to me and they had to be re-surgerized. Traumatic episodes and root things like that; broken roots, oblique fractures, horizontal fractures, that thing. And then retrograde clean shaping and obturation from the apical end. And when you start to learn this, you can apply it to a lot more and all of a sudden you have a whole field.

So here’s what’s coming. And right now this is not – and just in time. Oh, my producer is going to want something very obvious. This is all coming. We’ve done Ruddle Show stuff. This is like almost our 89th show, so maybe you can almost double that. I think not every show had two surgeries in it every season. But more or less every season since after the 2nd or 3rd season we’ve had a couple of surgery shows every single season, so there’s already 30-40 things you can look at. We will be talking and start-to-finish lectures I have about 18-20 hours here that I’m going to be able to share with you and show you. And we’ll do beyond surgery; that’ll be more lectures and teaching things from my library. And finally, we’ll have surgical podcasts; so we’ll have the clean, shape and pack, the non-surgical retreatment and surgery, and yes, you can do it.

Okay, so today we’re going to update you on a couple of really exciting and game-changing products that we’ll soon be launching in the dental world. And I say “update” because we’ve actually talked about these inventions on our show in the past, including Zooms with the respective inventors; but it’s been a while.

So first we’re going to hear from Dr. Randy Cross, who was on our show in the past as I just said. And he’s going to talk about the Endocator, which is a device that can test how clean the canal is. So let’s hear from him.

You go Randy!

[Cross Video Segment Begins]

Hey Dr. Ruddle, hope all is well. Thanks for having me on again. As you guys may or may not remember, my name is Dr. Cross; I’m the inventor of Endocator. A little bit of background. Last episode we talked about the biomarker I was using. I just really wanted to know if the root canals were clean or not, and so I invented a method to go ahead and test for that.

So I just want to give everybody a couple of updates. I’ve been testing all of my root canals to make sure they’re clean for the last three years. The information I get from it is just so interesting and incredible. And I want to go ahead and give everybody a little update. Since we were last on this show we’ve had a couple of research projects with the Sibar Institute of Dental Sciences. They had a 1000 patient study and Dr. Nagesh [Bolla] was able to show that most canals go from dirty to clean as you increase the file size and do a final activation rinse with the EndoActivator; but there’s a lot of variability in that. Some of those teeth are still really dirty and some of them are clean; and that goes along with my clinical results as well. Like you just don’t know unless you actually test for it, which hopefully goes to explain why root canals are perfect on an x-ray but they still fail. And the reason for that is they’re still dirty; they weren’t activated enough.

So I want to go ahead and give a couple of updates. We have a custom device which should be ready to be on sale here at the end of 2023, so very closely. The new unit is meant for endodontics, the unit and the testers are all custom, and you can see it turns on in 10 seconds. I’m going to go through a little live demonstration with you guys just to show some of the cool updates.

[Cross Video Segment Ends]

Okay, so we stopped the video there because in a moment we’re going to see Dr. Brett Gilbert demonstrating the device chairside on a patient. So what do you think about the progress that the Endocator has undergone?

It’s really a nice device, nice technology. I have come quite a ways myself in just what I have been able learn. Thanks Randy; I have mine. I’m swabbing everything; I’m swabbing my glasses, I’m swabbing my tongue. But what I’ve learned that’s pretty cool is that you’re measuring relative light units, RLUs; that’s what this is doing. So when ATP reacts with firefly enzyme luciferase, it gives out light. So we’re actually measuring light. So that’s one thing I’ve learned and gotten a little more up to speed on.

He simplified it. I think when he started it was 1-1000, then he’s got the scale. The scale on this would print out – or digitally would print out 1-100. And that’s good, that’s getting better. But I would like him in the future to get to a 1-10 scale and maybe even use color, like green, good to go, pack the case, you’re perfectly clean. Yellow is caution; maybe you’ve got to do something further. Red is stop; don’t pack today – we’ll talk about that in just a moment. So I think that could improve.

The other thing I’ve noticed is the research. I’m very proud of Randy because I know this from my own profitability; you’ve got to have research. So he went to India, he went to SIDS, Sibar Institute of Dental Sciences, and he’s working with a guy named Nagesh Bolla if I’m saying that correctly, and he’s the chair there and they’re cranking out some good research. They’ve done a lot of research on the EndoActivator, not to be confused, and they’re using the Endocator to verify those clean shapes. So a lot of work out of that institution; I’d like to acknowledge all of them for their good work.

Okay. Well why don’t we now watch the video of Dr. Brett Gilbert using the Endocator.

You go Brett!

[Gilbert Video Segment Begins]

I want to introduce you to a new device called the Endocator. This is essentially a biomarker indicator, so the concept is that I’ve completed my instrumentation, all my irrigation protocol, and now I can actually get an indication of how clean the canals are. So the process is really pretty simple. This device just sits chairside. It has a little opener, so I’m going to use this test tube and I’ll be able to cultivate and take a sample.

Now what it’s actually looking for is adenosine triphosphate, which is available in any biological tissue. So whether there’s blood, bacteria, tissue, any of that will be detected by it. So it’s a very simple procedure, so basically I’m just going to go ahead and I’ll flush with a little bit of water here.

So again, my protocol is complete and I’m just going to kind of flood the chamber with some water. And what I’m going to do is I’m just going to aspirate a little bit of the water back in. This is coming right in from the chamber in the canals just like so. And now what I’m going to do is I’m going to take this tube out, and all I need is a few drops just to go inside the test tube here. You can see there’s just a couple of drops. And then I use this swab to drag that down and put it together, just a little flick like so. And now what I’m going to do is I’m going to bring it into the Endocator, and it’s just very easy to bring it in, and then press start.

Now this is going to work on a scale that’s going to indicate what type of biological material is actually in there – it takes about 10 seconds – so this is chairside evidence. This is definitive evidence of how clean you’ve gotten the canal. You can see that’s a 2, that’s really great.

So this is called the Endocator. Again, biomarkers in endodontics. This is not like the old days when we were culturing bacteria. This is actually a biomarker to determine if there’s any biological tissue. Now if that reading was high, say above 50, then I would absolutely go back and do another irrigation protocol and reevaluate why I have biological material still in there. But with a reading of 2, I feel very confident at this point that I can move forward and fill this case.

So when you think about the implications of this, and chairside evidence, definitive evidence that the protocols we’re putting forward are doing the right work, doing the job thoroughly and effectively, I think this could be really amazing. So I just wanted to share this with you.

[Gilbert Video Segment Ends]

So I notice that he identified the biomarker as ATP; you said that too, adenosine triphosphate. And I only mention it because when we had Dr. Cross on our show before, I don’t think we could mention that. I think it was still proprietary information.

That’s right.

ATP. Well I do have a question. Say you test and you get a reading that is not acceptable. So I’m going to try to explain this from a layman’s perspective, because this is how I was thinking of it. So say you have a shoe and it’s dirty, and you dump a glass of water on it thinking you’re going to clean it, but then it’s still dirty. So I’m wondering if just repeating the same action of like dumping another glass of water on it; is that really going to make a difference? So do you have to do something more than just disinfect again if you are trying to – if you get a reading that’s not good and you’re trying to make it better?

That’s a good point – power hose for your boots. But back to this idea. There are things we could do, and that’s why I’d like to quantify it to a scale not even 0-100, because there’s more vagaries if there’s three things; good to go, green; caution – that’s what you’re asking me about – caution, yellow; and red would be stop. So let’s talk about those. If you’re green, you’re good to go, you pack. So you should have a high reliability that the case will be successful over time if it’s properly restored.

If you got a yellow reading and a score that was in that level, you would then know maybe I should go up a file size. So if I was working in the PRO-Taper family of instruments as an example, and I was using a 20/07, and I got a yellow score, I might go to a 25/08; that would be red. So we could use this to even dictate how minimally invasive we prepare, or maybe we need a bigger preparation.

Another idea is don’t go up in file size. You might just decide to use one more cycle of whatever your favorite 3-D chairside disinfection protocol is. So if it was the EndoActivator as an example, and yes for GentleWave – I’m a proprietary, commercially involved in the project; I invented it – there you go. So you might say use another protocol with the EndoActivator, and that would be another minute and a half.

You could say it is red and it’s so bad that I could go up a file size. I could do another protocol, but it’s still red. I would put in calcium hydroxide and close the case, dismiss the patient and have them back pretty much like we do anyway. Because calcium hydroxide incites you. It’s very basic; it’s going to react with acidic reactions, neutralize them; kills bugs, kills detached tissue. So the calcium hydroxide is well-known.

Okay. And then the other question that I had was so say you’re a pretty skilled clinician already, but you’re very intrigued by this device and so you purchase it. And you test – like your next 20 patients you test all the canals, but you’re really getting good readings every time. So you might think you know what? I just don’t really need to test anymore, because I’m pretty good at this and I’m getting – these canals are clean. So I’m just wondering if that happens -

Pride goeth before a fall!

Are there other uses for this device?

Yeah, that’s a good question. Because what you said, I’ve been talking to several clinicians – one was John West – and John West actually brought this up to me many months ago. Would you start to fall back to you’re comfortable because you’re getting these negative tests as you mentioned? Well I think for sure you would have it in every graduate residency program in the world. Because when you have residents out there, they’re trying anything and everything. So that means their shapes are smaller, they’re bigger, they’re all over the place in their shaping. That’s a variable; that’s a huge factor in disinfection is the available volume to have an irrigant reside in; the receptacle.

And then you might want to test your – I’m doing GentleWave disinfection. Next week I’ll do lasers, I’ll do Endovac, pulp sucker, so it would be a great way for residents to test. If they could freeze their shape, they could test different chairside 3-D disinfection protocols and see how their scores are coming in.

It would be great for research.

And then some – like lasers are very, very fast; especially the ones that are held in the pulp chambers. Still fast if you’re withdrawing it out of the root at a millimeter per second. But GentleWave is a lot longer, so you might make a very intelligent decision that I can not only get as good a reading, but I’m a lot faster than over here where I have to use a platform and all that.

So I think it’s good for students; it’s good for studying different research and shapes. There’s many variables that I’m not even talking about. I think industry would want it. If I’m a manufacturer of a disinfection technology, I would like to know before I ever sell my first unit that I know I’m getting reliable scores, and I’m measuring ATP and it’s looking really good.

So that’s that. Did I have another one here that might need dangling around?

I think you mentioned to me that it might be very useful in vital pulp therapy.

Oh yes! Beth Damas and her whole lecture. Maybe to play off you a little bit. So we are taking out the last bit of caries coronally, and we have a pulp exposure and there’s some red. What if we sampled that and found out it was pretty loaded with ATP? Maybe Beth told us to go to the pulpotomy because it’s a little bigger incision; broad margins to include complete enucleation.

So yes, vital pulp testing; regeneration. How about failures? How about exacerbations and flare-ups? So it would be really good in cases that came in, they were failing; previous root canal, big lesion, no lesion, but they’re hurting like crazy so there’s infection. You might want to test it after you’ve removed all the obturation materials, re-prepped and irrigated and done all that. You might want to just say am I clean yet? That makes sense doesn’t it? So certainly in retreatment.

Okay. Now in his video, Dr. Cross said that it would be launching – the product would be launching by the end of this year. But I think he made that video a couple of months ago, so is it on schedule to launch this year or are we now getting into next year?

I think your timeline is pretty good. I got mine. Oh yes, I think the audience will just love it if I show them. It actually has a little stand for chairside. But I think he’s seeing a wave-out this year, so the whole point is showing this. He sent out like 5000 – 7500 units to schools, academic people, researchers and clinicians, and so I know that wave went out. So you can see it came packaged in a box, it’s got DFUs, it’s got – Randy, you didn’t get all the languages yet. I notice the DFU is in English, and what if I’m Spanish? But anyway, I think next year though, by queue 1 or 2, for sure you’re going to see it as a for sale product.

I wanted to say one thing; this is a gem that nobody’s talking about. You know what? If you keep getting really high scores and you’ve gone up in file sizes, calcium hydroxide, you’ve re-doubled down on your protocol; it could be a fractured tooth!

Okay, that kind of brings us into the next one. So very exciting on the Endocator, and now we’re going to talk a little bit about InnerView. And we actually talked with or Zoomed with Dr. Cherilyn Sheets; her group is making this product. And that was back in Season 2, so it’s been a while since then. So let’s hear about InnerView. And I actually don’t think it was called InnerView at the time. It didn’t have a name. But what it is is a device that is for early detection of radicular fractures, crown fractures, you can find out if a crown is loose or not, it’s very early detection. So let’s see this video.

Okay.

[Innerview/Perimetrics Video Segment Begins]

[Product/video promotional clips including guests Robert Hayman (Perimetrics CEO, Chairman), Dr. Cherilyn Sheets (Co-Founder), Dr. James Earthman (Co-Founder), Dr. Bill Dorfman (Clinical Advisor & Stakeholder), and Dr. Dennis Quan (Chief Technology Officer)]

InnerView is the first ever technology that identifies damage in teeth. And by damage what we mean is cracks; all four of the major crack types, and also failing restorations.

This is a disruptive technology on many levels. It’s disruptive in the thought process of the dentist because all of a sudden, we realize that the structural strength is something that’s been invisible to us before.

Well there isn’t any other technique for detecting these sorts of defects in teeth. You can’t see them in an x-ray. Even a cone beam CT won’t reveal these cracks, because the space between the crack faces is going to be only a micrometer.

The thing that’s so innovative is we take x-rays; that’s standard for the industry. The problem with x-rays is you can’t see everything you need to see. For instance, if a tooth is cracked and you take an x-ray of a tooth like this, you can’t see the crack like this.

By incorporating this into a standard patient visit, and being able to track this over time, we can really understand how tooth cracks are developing over time, and hopefully catch them at an earlier stage. InnerView is using quantitative percussion diagnostics, and it’s able to detect discontinuities in the solid surfaces of the tooth regardless of how big or visible they happen to be. So that allows us to catch cracks, even if they are extremely small and undetectable by the naked eye, because they will show up in our measurements.

The handpiece is held up against the tooth or teeth, they’re tested, the data immediately goes up into the cloud, and the algorithms that have been created give us a score. At the end of the testing, whether it’s one tooth or an entire mouth, we will get a graph that comes back that shows what the scores were on all of these different sites.

One of the things that’s really exciting about Perimetrics and dental AI in general is the fact that we’re able to get key problems solved for clinicians. And using a device that’s highly precise and gives high quality data, those things actually lend themselves very well to creating a highly effective artificial intelligence system.

I think from a patient perspective, the biggest advantage is the fact that when you come in and you have your exam, and you go ahead and use the InnerView throughout your mouth, you’re going to establish a baseline. Once you have that baseline, if anything at all changes, you’re going to know exactly what it is.

To be able to have something that preventatively lets us know that there’s a structural problem starting, and then be able to give them counseling and some therapeutic aids to help stop or slow or even improve that situation.

They’re also able to use the information from InnerView to help explain to patients why certain treatments might be necessary.

InnerView is a wellness system like dentistry has never seen before or even imagined. But not for much longer. So when this finally launches and I think dentists can really see what this can do and patients can experience the benefits of this, it’s going to change the way dentistry is done forever.

[Innerview/Perimetrics Video Segment Ends]

Okay, so one really interesting thing about this technology – and this is also one of the reasons why we’ve talked about it so much – is that it incorporates AI; correct?

Yeah, AI is really what makes this product even viable.

And that’s probably why it’s been in process for so many years now, in production, because they're collecting so much data to help the AI.

You know they saw the clip, so they saw the guy named Dennis Quan. He’s the AI genius and he’s – you can Google him and we’ve already had him on the show in terms of his background and his references. But you have to have AI because there’s a handpiece – I don’t have it here today to show you, but there’s a handpiece. There’s a little nose cone that is quick connect; snaps on. And in the nose cone is a computer chip, and that computer chip gives you one hour.

So from the time you put that on, it knows the patient’s name, it goes in that patient’s file, it holds all the information that you saw on the test, how the lady did the testing, it goes right up to the cloud, and the cloud will send you back to your monitor an energy return graph, an ERG. And the point of coming back to Dennis Quan and AI is if you have millions of tests being fed in, the computer will start to look at these graphs, and every graph has a characteristic curve. And so certain curves mean certain things. So you could have a radicular fracture, but it might be able to tell you if it’s oblique and plays out in the coronal one third. It can tell you if you have a coronal fracture versus a radicular component – big deal, right – and then also it can tell you if it’s a crown failure versus a coronal fracture. Because cements do debond, they delaminate, and crowns loosen. And long before the patient hands you the tooth or says I have a bad taste in my mouth, you can get a baseline, a baseline. And from visit to visit, you can do this test in less than I think a minute in the whole mouth, and you can see a test that might become aberrant. So the shape of the energy return graph is what we’re learning through AI, because it means something.

Okay, well when I first watched the video that we just saw, I actually thought I wondered if a patient would think that repeated percussion on a tooth might actually cause a crack. I think that probably they thought of this, because Cherilyn’s company then also made a short video that you can show your patients when they come into the office. You can sit them down – it’s only like a minute and a half – you show them about the process. So that way they can know what’s going on and they can feel more comfortable with the whole procedure. So let’s actually watch that video now.

[Innerview/Perimetrics Patient Video]

Okay, very nice. So when is InnerView launching? Do you know?

Well I’m going to back you up a little bit. I think you might have been reassured when you saw the assistant showing the little hammer strike the tooth. It would be just like a clinician out there, taking their mouth mirror and doing all the little tap-tap-tap on the teeth… Oh, ouch! —

— Oh gosh!

It’d be like you doing a percussion test on anybody’s tooth. So it’s gentle and it’s [five] times [3 seconds per tooth]. So it will come out.

Yes, this is definitely going down the tracks. We get updates almost weekly if not monthly on the FDA status and getting the coveted 5-10K. So there’s companies that guide you through this, but we’re coming along nicely. So I think it’s totally appropriate to think early next year.

Okay, well that sounds like -

Diagnostic too. I mean we talk about files and do packing and this and that, but this is diagnostics.

Definitely two technologies that you might want to consider adding to your office next year. So do you have any closing comments?

Well I guess I want to acknowledge both of these people, because I’ve gone down the pathway and I’ve drug my family with me. So I guess you’ve been up close. But there’s the idea, the concept that you sleep on for a while and think about it.

That’s the easiest part.

Absolutely! Everybody has ideas, come on! Show me a person without and idea and they’re a robot. But they would have ideas too, wouldn’t they?

Okay, so anyway then you have to start thinking about R&D and that whole pathway. And then you start getting crude prototypes; they’re not working like you’d think. And without AI and your first test, what does that return graph mean? Does it mean blow up the tooth?

Anyway, so I want to just acknowledge them because then there’s the relentless meetings and Zoom calls and working with the manufacturer, working with regulatory, packaging, IP, lawyers, attorneys. Money is pouring into this like you can’t even imagine.

Directions for you?

Yeah, are you getting multiple languages, Randy?

Then sales and fulfillment.

And marketing, then we have marketing. So anyway, it’s a big journey. And in Cherilyn Sheets’ case this is like a – I’m going to say maybe 12-15 years everybody out there. It’s not a quick bam, bam, bam. Randy’s was faster. His all pretty much happened from grad school, which he got out I’m going to guess a year and a half ago, might be two years. Then throw in two years of grad school, so maybe four years for him. But with his idea, maybe five or six or seven. So it takes time everybody, because if it was easy, we’d all be coming to market all the time with new products.

But the main thing about these, these aren’t just new products. They’re diagnostic products that can change how we approach treatment planning.

Okay, well I know it’s definitely been a long journey for both of them, and the journey doesn’t end when the product launches. That’s just probably the beginning of a new journey. So we’re actually going to have him on our show in the future to talk the product’s journey post-launch.

There you go. So Randy, get ready for your next presentation. And Cherilyn, I talk to you regularly, and you are my dentist and I’ll be seeing you shortly. But be thinking about coming back on the show to tell them the good news.

All right. So guess who’s been doing a lot of thinking lately? Phyllis! So I think it’s time for another episode of What Phyllis Thinks. Welcome Mom!

Hi everyone. I’m here.

How are you doing?

I’m doing great.

Are you excited to give us your opinion?

Oh yes, I’ve been holding it for about six months.

All right. Well Phyllis, who is a Baby Boomer, she has five grandchildren who are all Gen Z, and that means that it’s individuals born between about the mid-1990s and 2010 about. And it’s not to be confused with Millennials who came before; Gen Z definitely has its own identity.

So today we’re going to talk to Phyllis the Boomer and see what she thinks about all things Gen Z; what surprises her, what inspires her, and maybe also what makes her cringe.

When she’s done, I’ll tell you what she really says.

Okay, so here’s your first question. So Gen Z is considered the first generation of digital natives; meaning that they’ve never known a world without the Internet. Do you think this makes life easier or more difficult for them?

I think both. It’s an amazing amount of information at your fingertips. But having grown up before all the technology, I know there are certain people who do not naturally have – they don’t even consider thinking that way and going to that. So I would imagine just like adults have had to adapt, and those who have it naturally, it’s been easier, but everybody’s had to. I see patients coming up to the door with their phone and they’ve likely got their walkers, and I feel bad for them because they’re having to adapt, text, say I’m here and all this stuff and it’s a whole different thing.

So kids the same way. I think some would naturally fall into it and others would have to really work hard at it. So definitely it’s changed everything.

If you could choose what generation or what time period you were born in, would you want to keep the time period you were born for your youth; or would you want to be born into this time period?

Well since I’ve seen it from the beginning because I did do coding back in the ‘60s, I enjoy the process. It still amazes me what my phone does compared to what we had in the ‘60s. So I liked being there.

It’s almost like a badge of honor to have been around and navigated life without this technology.

Phyllis follows the philosopher Maurice Chevalier; it’s good not to be young anymore.

This is true. I lived through the 1969-70 crisis, when the world was going to end. So when we went from 1999 to 2000, I knew it was going to be okay.

All right, next question. All five of your grandchildren, who range in age from 15-24, still live at home. What is your opinion about this because I know you were on your own at 18?

You know, it’s just different times. We lived in a generation where the goal was to reach 18 and get out into the world. It wasn’t really an option to live at home. I didn’t know anybody who lived at home. Even the ones who didn’t get out and get married right away like we did, they didn’t stay at home. So it’s just different times. And I think it’s great that they don’t have to grow up quite so fast.

Do you think that they should start paying rent at age 18?

That’s a tough one.

Be careful. Your grandson is producing the very video feed that you’re on, so he’ll hear that.

That’s true; I think he should pay rent.

Oh God!

All right. Well one characteristic of Gen Z is that they are considered to be money driven and ambitious. Do you find this to be true from what you have seen?

I would say money aware. My grandkids are not money driven, per se, but they have been taught from day one that the world is their – what do you call it ?

Oyster?

Oyster, yes. They can do anything they want. And so there are certain things, if you are able to provide it depending where you come from, they are taught to believe that anything is possible. And so they are money aware. They are very good shoppers and schemers. So when Isaac needs a new piece of equipment, he has researched in great detail and we’ll have conversations about there’s one for $50 and there’s one for $55. I could live with the $50 one, wouldn’t you think Meme? And I’m going $55 sounds fine to me. So he’s very aware and I appreciate that.

I actually think a lot of things that Isaac has bought the cheaper version, he’s ended up down the line having to buy the more expensive one.

They learn that too. So quality, yes definitely.

Okay. Well do your grandkids use social media? What platforms and what is your opinion, if any, of the way they use the various platforms?

Well, first of all I was shocked how many different platforms. I decided to look it up, and I only found the top 23. I was amazed at how many different things there are. And I’m aware of about half of them, but I had no idea there were so many. And in our family, your kids are definitely social media kids. Lori’s kids not so much. They’re aware of it, but they haven’t gone in that direction.

So we have a mix in the family, and I think the kids who do not use social media, they still use YouTube. They get their news, they go to all of the sports apps and all of those kinds of things. So it has definitely changed in the last 4-5 years even social media as the definition.

So you’re saying even the ones that don’t use social media still go online for information.

Definitely.

Yeah. I know my kids look a lot for inspiration on social media. Like for doing nails, or Isaac for ideas for his projects.

The things that they’re doing, definitely there’s so much information and it would be inspirational. If your interest is say politics, I wouldn’t really go to social media for inspiration these days.

Do you use social medial for social reasons?

I used to. I mean I used to use Facebook routinely. It was like a network of friends around the world. But it’s been different the last few years, and it’s almost like it shouldn’t be called “social” media anymore, because they’re not very social. It’s been an interesting evolution.

I went on something, maybe it was Facebook, yesterday. And I was scrolling down and I’m like – it said sponsored, sponsored. It’s like everything was sponsored. I didn’t even see anything from people I knew. I’m like this is incredible. I was scrolling and I’m like this is all sponsored stuff. So it’s interesting how they’re designing it now.

It’s definitely changed, yeah.

Okay. For Gen Z, diversity is their norm. They witnessed the first black president, gay marriage became legal, and gender has been blurred. Pronouns have a different meaning for you than it does for them. Do you enjoy their perspective?

I do. Because I compare it to when I was that age, when I was living within the framework of my family and stuff, and I think about I would love if my parents were alive. It would be a foreign language, totally. So I appreciate that things evolve and change. Some things I look at and I’m going what about common sense? We just still need some common sense.

Definitely common sense.

Okay, let’s finish with this question. We’re going to have to do a Part 2 of this because there’s a lot of questions. So about a third of Gen Z say they have anxiety issues. Why do you think this is, and would you say you also had anxiety at their age?

I think every generation has their own breed of anxiety. And today’s generation, there’s so much information every single minute. I mean there is nothing hidden anymore. So of course you’re going to be anxious about what’s going on in the world. And when I grew up, there was a lot of anxiety about nuclear war when you were a kid. Russia was going to invade when I was a kid. And there’s always been levels of anxiety in every generation. But I think now it’s on television. I mean the medications, the pharmaceuticals, everything is in your face every single day. So there’s not as much of an escape from anxiety, and that is a bit concerning.

And everybody’s an expert.

And it’s probably important to mention that this generation was in their formative years during COVID, so that’s probably –

That is definitely – yeah. That’s affected a lot of people of all generations. I’ve seen changes in everybody from that whole thing.

Yeah, I think that there’s a little extra difficulty from it being their formative years. Then if you’re already kind of – you’ve seen the world a lot and you know you can just deal with it.

I know. That’s true. Socially especially.

Okay. Well we will have to continue on with this later because we are running out of time. But I definitely want to continue on. I like this topic and I think our viewers will be interested in this topic. And another time we’ll do what Generation Z thinks about Baby Boomers.

Ooh! Good job Phyllis!

All right, thanks Mom. Thank you Dad. All right, that’s it for today. See you next time on The Ruddle Show.