Infrequently, but on occasion, patients present in dental offices expressing concerns regarding root canal treatment. Often, these patients have been exposed to misinformation...
Quackwatch & Pot of Gold Managing the Misguided Patient & Understanding the Business of Endo
Ruddle discusses how to talk to the fearful or suspicious patient who presents with misinformation obtained from professional “Quacks.” Additionally, this show will also give a better understanding of the business of endodontics and how to maximize profitability. Stay tuned to the wrap-up where we will learn “What Phyllis thinks...”
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Dentistry in the Movies/TV Listing (as of March 2020)
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: Dentistry in the Movies
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. Today on our show, I’ll just give you the titles of our segments, because they’re – it’s kind of like a teaser. You’ll see when we get to the segment what it’s really about. But the first segment’s gonna be called “Quackwatch”. Then, it’s gonna be called “Pot of Gold”. And we’re gonna finish our show with “What Phyllis Thinks”.
So, before we get started on that, I noticed just a couple days ago that they announced the nominees for the Academy Awards. And it got me to thinking about how dentistry is portrayed in the movies. And usually, dentistry is – in the movies I’ve seen that have some dentistry in it, it’s usually to either scare you [laughs] --
-- or it’s presented in like a comedic way. So – but not really just an accurate [laughs] portrayal of a visit to the [laughs] dentist’s office. So, I found this list that has 13 movies that have dentistry in them, and the top of the list is a movie from 1976, called “Marathon Man”, with Dustin Hoffman and Sir Laurence Olivier. So, it sounds like a good cast. Have you seen that movie?
What was the year?
Oh, yeah. That was the year I started endodontic practice.
[laughs] Because you graduated in 1974, about?
Right. Yeah. I was a young endodontist out and going to San Francisco with Phyllis to see “The Marathon Man”. It probably set our endodontic practices around the world back, like [laughs] decades. It was a World War II plot, and there was a Nazi guy that from World War II had stashed away some loot, some booty. And he’s looking for this, the whole movie. And of course, he finds people, and sometimes he has to encourage them to tell him where it is.
And he’s encouraging Dustin Hoffman by making accesses into his central incisors, without anesthesia.
So, it’s like, you know, it’s not really – it’s not even funny, but anyway --
It’s scary, it sounds like.
-- it’s really scary. And of course --
It sounds like you might post – wanna postpone your scheduled dentist [laughs] appointment for – to a later date [laughs].
After that movie released, appointment books across the nation and around the world were empty.
Another one on the list, and probably a lot of our viewers have seen it is “Finding Nemo”. And they use expressions in that movie, apparently. I have not personally seen it, but I know that they use expressions like “Schilder Technique” and “Hedstrom file”. What – do you know about that movie?
Well, I do, and that’s – that would be my favorite on your list of 13, because – as you know, because we talked about this, Nemo’s a little fish, and he ends up, through a whole story, in an aquarium in a dental office. Okay? And all the fish in the aquarium [laughs], they’re familiar with all the procedures, because they’ve heard them many times. They’ve heard the doctor-patient interaction. So, they’ve heard pros, they’ve heard perio, they’ve heard implants. But they really like when they’re gonna do endo, because when they do endodontics, they know the patients are afraid, and they – all of the fish are swimming faster, and they’re all getting really excited, and they’re talking about it.
But during the technique, they go, ‘Well, he’s got the rubber dam on now.’ ‘Oh, good, good.’ ‘He made access.’ ‘Oh, he’s using a Gator-Glidden.’ And of course, for our audience, you know that as Gates Gliddens, but they called it “Gator-Gliddens”, kinda cute. And then, they argue among themselves in the aquarium whether it’s a K file or a Hedstrom. So, it was cute, it was non-threatening to patients. Everybody laughed, went home and scheduled procedures the next day, in the endodontic office.
I think you actually talked to Herb Schilder around that time, and he was quite proud of that movie – of being in the movie.
Oh, he was very proud, and, you know, he was one of my disciples -- or I’m a disciple of his and have great – well, I really loved Herb Schilder and my mentor, Al Krakow. So, Schilder told me that, you know, he got consulted, and he threw some of these things in. And it made it interesting, with a little bit of a real perspective.
Neat. Well, just looking at this list, which, by the way, is on our website. You’ll find it there, as well as some little clips maybe from YouTube of some dentistry scenes in some of these movies. We just can’t show them to you here because of copyright reasons. But just looking really quick, I see Steve Martin is in a couple. Maybe a lot of you have seen “Little Shop of Horrors”. There’s an Alfred Hitchcock movie, a 1932 movie called “The Dentist”, with W.C. Fields. So, what would you say is your favorite portray of dentistry, in either a movie or a TV show?
Well, we mentioned “Nemo” is my favorite movie, and I guess – what was it? The “Carol Burnett Show”? Was that a television show?
Oh, yeah. Okay. That was – yeah.
Yeah. That’s my favorite, just if you wanna laugh, and I mean laugh really hard, till you need a hankie, because you’re gonna cry. But --
It’s with Harvey Korman and Tim Conway, I think, that scene?
-- yeah. Tim’s the dentist. Harvey’s the patient. And it doesn’t go well. Okay?
There’s lots of mistakes, and Tim is funny as can be. He tries to give anesthesia, but he inadvertently injects his thigh. So, he’s limping around the operatory, and he’s got his notes up from dental school, what to do next, and Harvey and him are cracking up. It’s --
Oh, yeah. Harvey Korman could never keep a straight face [laughs] when Tim Conway was doing stuff. [laughs]
-- so, if you wanna laugh, that’s the one you wanna look at. And if you wanna just share a moment with a patient, go see “Nemo”. But maybe what they should do is, our audience, and you’re quite diversified, maybe you should look at some of these or at least a few trailers, and then, let the show know --
How accurate the portrayals are, what you liked the best.
-- and what their Oscar is.
Best film of the year.
Okay. That sounds great. Let’s get started with the show.
SEGMENT 1: Specific Scenario – Patient Presents with Misinformation from Quacks
Sometimes patients arrive in the dental office and have major concerns about receiving endodontic treatment. And a lot of times it’s because they have misinformation from maybe people who claim themselves to be holistic experts or from the internet. A lot of times, these patients can be reassured, and let me say right off that these patients can be – just be simply misguided, but they can also be fearful and suspicious. And some are even just downright argumentative. And these patients can be reassured, most of the time, if the doctor just takes the time to address their concerns and answer their questions.
There are only a few that will remain argumentative and embrace misconceptions. And sometimes these few are the most vocal. But can you tell us why there’s this idea that endodontics is somehow dangerous and contributes to systemic disease?
Yeah. I can, and it’s kinda funny how, here we are in 2020, and we’re still talking about stuff from the 1800s. But let me explain. Weston Price was a well-known dentist, with respect, respected, and what he did, he had a long life, from about 1870 to 1948. But what’s important is, he did quite a bit of research towards the end of his professional life, and he did 25 years pretty much on endodontic disease and the ramifications of endodontic disease on systemic disease. And so, what he oftentimes did is, he would take teeth – maybe we can bring up some endodontics that’s a little less than ideal. Ha! Kinda disgraceful endodontics.
But anyway, this is not the teeth. These are just teeth from my practice, but he took teeth that would look much like this, teeth that didn’t have any remotely complete endodontics performed. And he would grind these teeth up and take the substrates and implant it under the subcutaneous tissue of a rabbit. And of course, the rabbits got all kinds of brain disease, they got kidney, they got hypertensive, call – it caused a lot of systemic problems. And so, he began to make the association or the connection between failing endodontics and systemic disease.
And I wanna re-emphasize, the research was done in dominantly the 1800s, the late and the wrap-around, a little bit in the 1900s, and we didn’t really have the technology. We didn’t have the biological foundation or basis for endodontics. And he made these causal connections. Well, he had a student who was named Meinig, and Meinig practiced just in a little eclectic town down the road from here, about 30 miles south and east, called Ojai. And in this community, you have a lot of thinkers, philosophers, sports medicine. It’s a really cool little community in the mountains above us, as you know. And Meinig became a real big disciple of Weston Price. And then, he wrote a book, “The Great Cover-Up”.
The “Root Canal Cover-Up”.
The “Root Canal Cover-Up”. And I think it went on to even say, what, something like ‘what they never told you’. So, anyway, we begin to see, in the 1900s, when this work was published, in 1993, his book, he began to show a lot of really bad endodontics. And he was playing off of Price, and he was saying that a lot of patients do suffer all these medical maladies, because of bad root canals. So, both men recommended that if you need a root canal, you should have the tooth extracted. Both men recommended that if you had a root canal, there was some controversy, but maybe just get it out, even if it’s fine, and there’s no lesions radiographically, and the patient’s comfortable.
So, we got these two guys, and then, everything subsequent was based off these two guys and a few others, but from another era in time when we knew less. And I should point out the importance to – for perspective to our audience. It was only in 1963 that the American Dental Association recognized endodontics as a specialty area of dentistry. So, what does that mean? Well, when you have endodontic programs spring up around the country and subsequently around the world, all of the students begin doing formal research. This research is published, and this published research becomes a foundational body of information that we learn and grow and trust. It’s the evidence.
They didn’t have this, back then. There were no endodontic programs. So, it was the blind leading the blind. But with all this said and done, I guess I could make a couple more comments. The ones that really probably bother me the most are maybe what I’d call more modern-day quacks, like Mercola, the TV show. He is an author. He’s on the “New York Times Bestseller List”. And he said that basically, on autopsy, on post-mortems, that 97 percent of all people that died of cancer had had a root canal.
Well, you know, I was thinking, out of all those dead people of cancer, I was wondering if any of them ever smoked. I was wondering what their diet looked like. Maybe they died because they all drove cars. Maybe that’s what they had in common. So, in other words, it’s easy to make connections, but we need the science, to really be clear. So, you know, we know the modern-day like Hal Huggins, he recommended all amalgams come out, because they were very toxic. And you know, he went to jail. He served time. So, maybe you should tell the audience a little bit more about what a quack is. I think most dentists, if you ask them, they would have a definition. But I think you have one that you found, that’s really appropriate. It’s really good.
Yeah. Let’s look a little closer at the definition that Steven – Dr. Stephen Barrett gives. And for him, he defines “quackery” as ‘the promotion of unsubstantiated methods that lack a scientific plausible rationale.’ And then, specifically, ‘Promotion usually involves a profit motive. Unsubstantiated means either unproven or disproven. And Implausible means that it either clashes with well-established facts or makes so little sense that it is not even worth testing.’ So, do you – now that we know this definition, do you think that it is the case that Price, Meinig, Mercola, and Huggins could possibly be considered quacks?
Well, yes and no. I mean, let’s be kind. I don’t know how they’ll judge our work and our evidence in another 50 to 100 years.
But the first thing I’d like to say about Weston Price, he was respected in the field, at that time, and again, he didn’t have the technology, and they didn’t have the scientific foundation that we have today, and there was really not a body of literature. So, his early steps were probably important, because even though we showed some really bad – badly performed endodontics, sadly, that’s a lot of what was in Meinig’s book. And --
Doesn’t Meinig, though, allow for – there is a possibility of good endodontics? I mean, I think that he says most endodontics is bad, and everyone’s doing it bad, but it is possible to have good endodontics. Doesn’t he allow for that possibility?
-- well, it’s funny. I wasn’t gonna bring it up, but I bought his book, because so many patients in the ‘90s were coming into my office with the book under their arm. And there were sometimes scared, as you said in the opening, fearful. Sometimes they were, ‘Is it true?’ And some of them were like, ‘Okay! Aha! I gotcha! You wanna do a root canal but look at how bad this is.’
So, I got the book, and to my surprise, he had one of my cases that he pirated [laughs]. He never asked me for permission, but he showed a case that I – he showed some anatomy. It was a fun case, and he said that if endodontics could be done like this, he wouldn’t have a problem with the field of endodontics.
But he said, regrettably, a lot of the endodontics that’s done is not looking like this. And so, in his book, you can turn page after page and pretty much see – I showed four examples of failures. Everybody could look at those and laugh, but we could show better and better cases that are still failing and better and better and better, and they’re still failing. So, there’s a wide range. We can show one for a laugh, we all get it, and we can show one that maybe Ruddle did. And I’m going, like, ‘Wow. How come the patient’s symptomatic?’ So, there’s subtleties of failures, too.
So, I think the – to answer your question, I wouldn’t really get real hard on Weston [sic]. I think Meinig went a little bit over the top, because he knew better. And really, the answer is education and turning people on to the evidence that exists. But Mercola and Huggins and some of these modern-day people, for me, they are quacks, because they’re working completely without recognition of science, and it’s self-serving, and you already gave the definition. A lot of it was for profit motive.
Okay. That’s just what I was thinking, when you were talking. So, obviously, the internet exacerbates the misinformation that’s out there. What can you comment on that? Can you say anything about that?
Let’s have the next slide.
Okay [laughs]. What I’d like to say about this slide is, when we walk in – well, maybe I should pose a question. So, what’s the difference, Audience, between a public library and a medical library? You’re thinking, you’re thinking, you’re thinking. Well, in a medical library, you don’t know what’s going on, but in a public library, they at least have the courtesy to distinguish the fiction from the non-fiction. So – supposed to be a little joke, but --
-- when you go to the internet, I think you and I have discovered in the last 10 years, working together, that people a lot of times go to discover things they want to validate. So, if you’re not for a vaccination for your child, you tend to go to the internet and find out all the crazy stuff about the anti-vax people. And you can find a lot of stuff, quackery, that can support your position. So, people tend to go to places to support what they already believe to be true. So, the internet isn’t good, the internet isn’t bad [claps hands], it just is. And it – there’s a tremendous amount of wonderful knowledge on the internet. It’s just that there’s no flag there that says, ‘Fiction’, ‘Non-Fiction’.
So, how would you deal with patients who come in and have this wealth of misinformation? Like, how can you talk to them?
Oh, you know, I’ve done it all different ways, and you’ve heard it. But I think we’ll just cut to the very chase. First of all, don’t be confrontational. That doesn’t help anybody. Be a very good listener. So, zip it up, and listen, and once they’ve expressed how they’re feeling, then I think you can talk with confidence – confidence. I think you should gently and in a non-confrontational manner explain that we have 50 years of research, up to 2020, and we have wonderful science. We have collaboration from different universities around the world that look into different areas of interest. And we really can learn a lot from using the internet wisely and speaking with confidence.
I don’t think we should argue with our patients. In fact, what I typically say to today, if you come in and you express – if she’s fearful, I got her in the bag. I can convince her, she’s good. She’ll have the treatment. We’ll be fine. If she’s a little bit fearful and confrontational, she’s just scared. I can still work with that. When they come in, and they’re pounding their book and the magazines and they have their print-out, this thick, and it’s highlighted, and they start to read, I don’t really have time for that. So, I know the stories already.
So, what I’d like to say to her would be, if you were the patient, is, ‘Lisa, you’ve been listening to a lot of people, maybe a biologic dentist or holistic dentist or friends that are ill-informed. You’ve been watching things that maybe are not true, and you have been maybe reading things on the Net or in magazines or newspapers that is inaccurate. And you have a very strong feeling, and I respect that. So, we’ve had a good consultation today. I think you should go home and reflect on what we’ve talked about, and if you would like to proceed with treatment, just give us a call. We’ll know how to schedule you.’
So, basically let them know that you’re there for them.
I’m always there for them. But we don’t have to get into this big stuff [clashing fists together]. You’re not gonna win that one very often, unless it’s just, ‘I’m afraid.’
I’m wondering what – someone that just is – insists on arguing, I’m just wondering what [laughs] their goal is, for you to say, ‘You know what? You’ve convinced me. I’m closing my doors today.’ [laughs]
Well, I usually – from dental school, I had an old pair of dentures that we made patients, you know? And then, we had models, the back-up dentures. Because the ones we actually delivered were in their mouths, we hoped [laughs], still. But there were other sets. So, usually if you’re in the operatory, you just hand ‘em a pair of dentures and say, ‘You’re well on your way.’
[laughs] Okay. That’s great. Lots of information. Let’s go on to the next segment.
SEGMENT 2: Pot of Gold
This segment is called “Pot of Gold”. When we talk about the pot of gold, and you can see this pot of gold here behind me, we are referring to the large number of undiagnosed endodontics that occurs every year. This is important because not only are dentists and endodontists missing out on potential work and income, but also, patients probably aren’t receiving the appropriate care. Let’s put up the table that shows the financial ramifications of undiagnosed endodontics, and you can tell us a little bit more about it.
Thanks. First, I wanna explain a little bit about the graph that I’ll talk about specifically in a moment. But the profession is very good at finding toothaches. So, dentists are excellent at finding people that come in, report a problem, okay? That’s not what we’re talking about today. What we’re talking about today is people that come in, reporting no problems, they’re asymptomatic, but they have a tooth that is irreversibly involved. So, if we have a continuum, and this is total health, and this is gangrene necrosis, total death.
This continuum, most pulps march down that continuum. They can stay at any position for days, weeks, months, or decades of their lives. But then, there’s little events that happen that keep pushing the pulp down towards gangrene necrosis. So, pulps go through inflammatory conditions, ischemia, infarction, necrosis, and pulp death. So, let’s now look at the graph, and let’s begin to understand, are you really diagnosing your endodontic teeth that come into your practice? You’re doing a lot of crown and bridge. You’re doing restorative procedures. You’re working on teeth all the time. That’s what dentists do.
Are you aware of the status of the pulp, before you pick up your handpiece and decide to [makes mechanical drill sound] and go to work, and dentinal smoke’s blowing through your hair. It’s a marvelous feeling. You love it. But you have no clue what’s going on with the dental pulp. So, now, let’s go to the graph. How do we get these numbers? Well, if you’ve been a dentist, and you’ve been out for, like, say a year or 2 or 3, you’re going to have accumulated 1,000 patients. So, if you have 1,000 patients, let’s assume for fun that they only have 20 teeth. They could have 32 teeth, they could have 2 teeth, they could have no teeth. But I’m saying they have 20 teeth. So, 20 times 1,000 is 20,000. Your math is great.
Now, if you see 20,000 teeth, and you’re not routinely doing endodontic diagnosis, which we’ll talk about in just a little bit, then we could say, ‘What if you missed endodontic diagnosis 5 percent of the time?’ 5 percent times 20,000 is 1,000 teeth. And Lisa -- just made this up, but she’s the Insurance Czar for North America, and she declares that all root canals are allowed a $500 insurance hit. So, you get 500 bucks. It could be $1,000, it could be 1,500. Plug in the right number for your community or your specific fee. So, you could see that if you missed endodontic diagnosis five percent of the time, you’re sittin’ on a half-million dollars of teeth that never got treated.
And what if you were working on those teeth just recently, last week, last month, and what might happen, and we’ve all seen that. What might happen is, the patient comes back two weeks after you cemented the bridge, and they say, ‘It’s killing me. It never even hurt [laughs] before I saw you.’ So, then, you’re back-pedaling. That’s because we didn’t do the diagnosis. So, I want to encourage each of you to become fabulous diagnosticians, okay? And find that pot of gold.
I just wanna ask you, so, say you find 1,000 teeth that needs endodontics. Are all of those patients gonna immediately make an appointment to get a root canal?
Well, that’s a good point. So, remember, the trust is between the general dentist and the patient. The patient didn’t vote for the specialist. They voted for the general dentist. So, they have this special relationship. So, because they voted for the dentist, there’s usually trust. So, when you trust somebody, and it’s in your best interest, the patient’s, you usually do what you’re told. So, about a third of them would probably say, ‘Well, can I make an appointment?’
Another third would probably say, ‘Gee, I wanna have it done. I’d like to make an appointment. But my benefit year, my insurance year, just got exhausted. I have no more income from my insurance company. Can we postpone it till my next benefit year kicks in?’ We find that a lot. Well, if they’re comfortable, fine. We’ll wait and watch, and we’ll schedule it. About another third will say, in the loudest voice, so it carries through the entire operatory, they say, ‘It doesn’t hurt! [yelling]’
Or ‘I want a second opinion’? [laughs]
Well, I learned an old expression a long time ago from an old Yugoslavian guy. And ‘He who speaks first, loses.’ So, you zip your mouth, and you say, ‘Well, then, just take care of it three days before it flares up.’ [winks]
All right? So, that’s kinda what you’re missing in terms of endodontics. There’s an important asterisk at the additional income part. And what that means is, most teeth that get endodontics get some kind of a casting or a restoration following endodontics. And if you said that all castings or crowns cost 500 bucks, low-ball number, you know that some of our crowns that we’ve had can cost 1,000 to $1,500 in Santa Barbara. But you could double all those far-right numbers in that column, and that’s how much missed dentistry is just not being identified. So, to me, to close this out, I get very emotional about this.
Throwing [bleep] around. Okay. What I wanna say is, it’s about patient care. You wanna treat your patients like you’d like to be treated. So, if you are a better diagnostician, whether they go through with treatment or not, you’re doing the right thing.
So, why are all of these endodontic diagnoses being missed? What are dentists doing or not doing versus what should they be doing?
Well [laughs], that’s very good. Okay. So, it’s not like a dentist didn’t learn in dental school how to do a comprehensive oral exam, including endodontics. But most dentists – do we have a hammer? Well, here’s a --
I don’t [laughs].
-- hammer. Most dentists do this. So, they’re gonna come in, and you’re – they’re gonna do a crown on you today. So, you’re going in to have a casting done. Most dentists go [tapping on tooth with “hammer”].
I think we have a slide to show.
Yep. We can bring up percussion. They love to bang on teeth. I was trying to do this. I thought they might know, back in that control room, you know --
-- like [bleep] ‘he’s doin’ percussion.’ Anyway, percussion is what dentists love to do, because if there’s inflammation around the root, then, when the tooth moves against the injury, it hurts. And that might tip off the dentist to do a little thorough exam. And then, we love to look at films. So, it’s nice to look at films. But you remember, x-rays only show resolution to about 50 microns. So, a lot of the early lesions, we do not detect. So, if we – if percussion’s negative, and they’re not hurting, they’re not complaining of anything, they can chew equally well, left or right, most dentists are going right ahead and working. So, that’s the two tests that dentists love to do.
Well, also, it seems like maybe – that I’ve always heard to say to take three well-angulated radiographs. So, maybe they might take one, and you – they can’t see anything.
Right. In this case, I’m showing this because we have a huge lesion of endodontic origin, apically, right? But if you think of the lateral root lesion, how many of you saw that? You know? You got that little [makes rrr sound] something’s draining out here. It’s a portal of exit. So, dentists are finding this. They’re not having any problem with this. Take away the lesion in your mind. Imagine. Perfect bone, perfect trabecular bone around the root. Imagine it’s asymptomatic to vigorous percussion or a bite test, you’re chewing on a tooth sleuth or a cue stick. They’re off and working and doing general dentistry.
So, what should they be doing?
Well, let’s pull up the slide that would be the Bible. And the slide would be what they learned in dental school, but they have ceased doing. Now, we learned in dental school about gathering the clinical findings and all that that entails, discolored teeth, discovering decay or caries, existing dentistry, perilous tracks in the gingiva, free gingival margin, attached gingiva, line mucosa. They’re lookin’ around, doin’ all this stuff, but sometimes when we get in practice, we get busy.
See, general dentists have a lot of hats they wear, and they have a lot of disciplines they’re doing. It’s like a gear box. They’re shifting from operative to restorative, and then crown and bridge and then endo. And then, they’re doin’ an implant, and then they’re restoring an implant. Then, they’re extracting a tooth. They’re going through the gear box of life. And they are really good in their perio. They have perio departments, they have a hygienist. They probe every tooth, they record the information. Okay? In endo, it’s [tapping on teeth], film’s good? Good! Let’s go to work! [claps hands] But they’re not discovering the health of the pulp, and that can only be determined by a vital pulp test.
Now, in another segment, we’re gonna go through each one of these, and we’re gonna talk about how to do the clinical findings. You already know, but we’ll show you some interesting stuff. And then, we’ll show you how to do vital pulp tests, because a lot of you --
Wait. I think we did vital pulp testing already.
-- then, we have a segment that they can watch that will be released on that. And then, of course, we’ll talk about radiology and CBCT and well-angulated periapical films, and all that.
Well, speaking of CBCT, I’m assuming that most general dentists’ offices don’t have a CBCT machine. So, obviously that would be very helpful in diagnosis. So, what – do you have any comments on that?
I do. It’s been estimated that maybe five percent of all U.S. dentists have a dental operating microscope. They also have, about five percent have CBCT. So, what we can say is, the vast majority of dentists do not have CBCT. The reason she brings up CBCT is, again, well angulated films show us resolution about 50 microns. That means, we don’t see a lot of the lesions. There are lesions present that we cannot detect with the technology we’re using. CBCT can pick these off, a lot earlier, so we can see truly the more incipient lesion. Maybe this next graphic will bring this home. We can bring up the three-tooth graphic.
This is the proximal view, and this is the mandibular bicuspid. So, you know, over here you can see we have a little gum covering the heavy cortical plate. We got the marrow bone, and then we got our pulp. And when we take a film and expose this, oftentimes when the pulp begins to break down, as the irritants leave the root-canal system, it’s an irritant to the bone. The bone pulls away, and we see a lesion of endodontic origin. Or do we see it? So, the problem is, dentists a lot of times – I could’ve made this half the size or twice as big, but a lot of times, dentists don’t see that.
In fact, if you look at the famous study by Seltzer and Bender, back in the ‘50s and ‘60s, they had their residents take jaw bones, human jaw bones, section them anterior, posterior, and divided them into a buccal and lingual half. Then, they had students take 6 and 8 round burrs and remove this marrow – loose marrow bone, put the halves back together, and expose the film. Trained endodontists did not see the incipient lesion, until the lesion expanded, impinged on the cortical plate. And only then did dentists say, ‘Oh, there’s a small lesion.’ So, just because you don’t see a lesion doesn’t mean there isn’t a lesion, and not all teeth that have lesions have percussion tenderness.
So, we really do need to do the vital pulp test, the clinical findings, and the radiographic exam. And then, of course, as these – this marrow bone gets punched out, and we break through the cortical plate, that’s when we start to see swelling. So, this is when they really hurt, when all the edema is trapped between these cortical plates. But once it breaks out, they’ll say, ‘Yeah. It’s swollen, but it hurt a lot more last night.’ Well, last night it was burrowing through the cortical plate.
I guess in this picture, you’re showing that there’s a cavity up there, that’s repaired, but yet they’re missing --
Now, that was really good!
-- oh [laughs].
I wish all dentists around the world saw what you saw. Now, we have superb dentists. I’m not takin’ shots at dentists. But I just want you to be sure that you’re really all you can be, and how you get to be all you can be is, you have people do these tests. Now, in California, Registered Dental Assistants can actually perform vital pulp tests. They can take films. They can do recordkeeping. When I walk into a room, I already know the clinical findings. The vital pulp testing’s all been done. I can see the hot and cold tests. And I got radiographs to look at. Okay?
So, back to your point, here’s caries in a tooth – very good! And they’re seeing the caries and restoring the caries, and they never saw this, because probably it hasn’t – wasn’t big enough for their radiographic machine in their office, to necessarily detect that lesion.
So, then, this becomes a problem, because maybe they’ve already – the patient’s already paid to have a filling, and now, they’re gonna have that all removed, right?
You had mentioned earlier about the importance of teamwork and working together. And I think what I’d like to say about what you’re saying is, we need to grow these – our general dentists and their staffs, okay? It’s not just the general dentists. We need to grow the staffs. I mean, auxiliaries should learn how to do a lot of these simple kinds of tests. First, they should do it on other assistants. And then, they should do it on hygienists. And then, they should do it on the receptionist.
And finally, when my staff, I thought they were gettin’ pretty good, I had ‘em pulp test me. And when they could retract and be gentle and they could do the test clearly, record stuff, then we’d start to turn ‘em loose and let them maybe have a little bit of help from another assistant. But finally, they’re flying, and they’re doing all of these tests for you.
Yeah. I’m just wondering, because like when I schedule my six-month teeth cleaning, which has a dentist check at the end of – after my teeth are cleaned, they schedule an hour, and, you know, I have my teeth cleaned. They check the pockets. They maybe tap on my teeth, like you said, a few times, and they ask me if my teeth are fine. And that’s pretty much it. I don’t see – like, I don’t know how long it would take to do a thorough endodontic exam to see if there was any endodontic problem. But it seems like – would that have to be another appointment, or do we schedule two-hour appointments? It just seems like – you were saying how dentists have to wear several hats, and obviously they’re going to have to prioritize certain things. So --
It probably all starts, Lisette, with leadership. So, if the dentist in the office is well trained and trying to take care of people, because that’s who they’re there. They’re there for oral health, and they do everything to support oral health. Then, it starts with leadership and just telling the staff that, ‘From now on, before I prepare any tooth for the most simple restoration or very complicated casting, let’s do the vital pulp test. Let’s know where that pulp is, on that continuum. And if we find out it’s already past the reversible, then we’re doing a root canal first, then the restorative work.’
Patients are much more accepting than that, than to do the restorative work first. That’s another procedure on the same tooth. And if it was already diseased, then, oftentimes the patient’ll have symptoms. They’ll flare up, and they come back in your office, and now, they’re doing that. [pointing finger] ‘I never hurt, until you convinced me. You twisted my arm! You had me get the bridge! I never wanted the bridge!’ [angrily] So, let’s communicate for no surprises. Let’s have leadership show up. And then, of course, training.
Right. And then, okay. So, I understand if the endodontist is counting on the general dentist to make a proper diagnosis, and maybe they feel like the general dentist that refers to them is missing a lot of diagnosis or maybe not doing a proper endodontic exam. How does that endodontist approach the general dentist so as to not seem like accusatory or blaming or, ‘You’re not doing your job’? Like, how do you talk to that office?
Oh, good. Well, pretty much in life, regardless of whether we’re talking about wealth, practice, sports, it’s always about communication. So, I think what has to happen first is to grow people, make them more successful. The more successful they are, the more successful I am. The more I help them detect endodontics, the more likely they are to refer endodontics. And of course, we teach in Santa Barbara, and I have for 45 years, ‘May your reach exceed your grasp’. In other words, I want dentists to try new cases, to grow, to keep learning, tackle a little harder case. But at some point, I think it’s important, if you see a lot of missed diagnostics, because a lot of times, to your point -- I’m off on a little tangent.
But the patient’ll say, ‘I was hurting for a week, but they couldn’t find it. And finally, they said, “Go see you, Cliff, Dr. Ruddle.”’ So, they come in and see me, and my assistants find it in three minutes. So, what we learn to do with – if they’re missing it, we realize they’re good people, and they can do exquisite dentistry in many areas. But maybe their endodontics is a little deficient. So, we have a conference room in our office. Several thousand of you have been there, ha, ha, over, like, the last 45 years, because we had seminars. And what we had is a granite table, and that was the seminar day, then, we had the workshop area. That seminar table’s used almost all the time.
We have – my receptionists will have other receptionists come in, and they’ll lunch and learn. And they talk about collections and billing and insurance and regulatory and all that stuff. And then, we’ll have the assistants invite other assistants from the community in, and they’ll lunch and learn. And they’ll have a session on, ‘Well, here’s how we do vital pulp tests. How do you do it? And if you’re not so sure, we’ll show you, and we’ll do it on each other.’ And by the time they leave, they’re goin’, ‘Geez, I can do this.’ So, they go back to their doctor and make him better, make their patients get more appropriate and timely care, and everybody’s winning, and we’re havin’ fun.
And that’s --
And who do you think they think about, when they do need to refer? [laughs]
-- [laughs] you, the person who had all the teamwork emphasis and the communication. Yeah. I really – I really like that it’s not just doctor talking to the doctor. It’s the whole staff, dealing with the staff from your referring doctor as well. That’s – I really like that teamwork emphasis.
So, you’re my kid, right?
When I told you something 5,000 times, before you were 20, it didn’t make any sense to you. But when Harry, across town, told you, you’d go, ‘Wow! That’s really important stuff!’ [pounds fist on table] So, a lot of times, when Cliff tells ‘em, or their doctor tells them, that’s one thing, but when peer to peer tells them, sometimes that’s what works.
Okay. Well, do you have any closing remarks?
Well, I’d like to come back to the pot of gold. Okay. So, you know, there’s an old expression, ‘At the end of the rainbow, there’s a pot of gold’? Well, my assertion is, there is a pot of gold, and it’s within the teeth that visit you daily. Music playing]
CLOSE: What Does Phyllis Think?
Okay. So, to close our show for today, we have a special treat for you, a segment we call “What Phyllis Thinks”. Phyllis is my mom. She’s been married to my dad for, I think, like, 52 years? 52?
And what a lot of you don’t know is that she actually has her own Fan Club. She’s pretty popular. After my dad lectures, he gets swarmed by a group, and then, my mom also gets swarmed by a group [laughs], a separate group. So, this segment is for her Fan Club. So, I’m gonna ask her some questions, and we’re gonna find out what she thinks. What did you initially think about The Ruddle Show idea?
I thought it was a great idea. I did not think it was going to take this long to get it together. I didn’t think we would actually be the ones running it. I thought, ‘He has a great idea. Let him go do it with somebody.’ And here we are.
So, what do you think about it, now that we’re on the ninth show of our first season?
I find it very exciting, and I’m so proud of everybody and what they’re doing. It’s amazing, the team that we’ve had to become, to get to this point.
Wow [gives Phyllis a kiss].
It’s exciting. [laughs]
[laughs] What do you think about bringing pets to the office?
Absolutely fine, if they’re quiet and well behaved.
Just so everyone knows, Cassie comes to the office, every single day [laughs].
My [emphasized] dog. No, actually, I’m her human. She – I had no intentions of doing that, but she was – she’s a Spaniel and was just so anxious when I got her that she wasn’t gonna be able to stay at home. So, she’s at the office, every day.
I have to say, when she’s not there, it does seem like [laughs] something’s missing.
I know [laughs].
Let’s just say this. If I died, she’d be sad for five minutes. If Cassie died, it would be a massive memorial, for weeks and weeks, years.
Okay. What is one thing about Dad that you really admire?
I would say, the most that I admire about him is his ability to teach. It absolutely blows me away, the way he has the energy and the excitement and loves the topic and will teach 1 or 1,000 and never gets tired of it.
That’s true. And what is one thing that Dad does, that you find a little bit annoying?
Or a lot annoying?
Is this when I should leave the set?
He doesn’t have an inside voice.
[laughs] Oh, that’s true.
He only has an outside voice. Doesn’t matter if we’re in the bedroom, reading the newspaper, it’s the outside voice.
[laughs] Okay. What – I’ll ask you a dentistry question. What do you think about GentleWave?
I don’t – I haven’t really formed my opinion 100 percent yet. There are wonderful things about it, that it can do, but it’s not a complete picture for me yet, knowing what I know about root canals, endodontics, from start to finish. So, I think there – they have a great idea, but it’s not quite there yet. And my only interaction with it is when you had your root canal, and they used it, and it wasn’t a positive thing in the family. So --
If you had a root canal, would you have it used?
-- absolutely not.
I don’t trust it yet.
What do you think about minimally invasive endodontics?
For years, I was the one setting up the scenarios for the workshops, with the extracted teeth. And I had to set ‘em up through little tiny accesses, because I was supposed to be making it like in real practice, where it was under access, you know, little tiny holes going in. It was so difficult putting in broken instruments, posts.
But when I would do a really nice access, he’d say, ‘No, that’s not right, because that’s not how they’re doing it. That’s why they’re breaking the instruments.’ So, for me, it just makes the most sense to have an access that you can really get in there and do everything you need to do.
So, appropriately invasive endodontics.
[laughs] You and Dad travel a lot in conjunction with Dad lecturing and giving workshops. What do you think about all the travel?
There’s pros and cons. We have a great time together. Flying is hard for me. I get headaches. I get altitude sickness. So, that’s always a bit of a challenge that I have to overcome. And hotels, I don’t care if you’re in the best Four Seasons or if you are in Motel 6 down the street, they all have a great thing or a weird thing. Every single room we’ve ever been in, there’s always pros and cons. The people make it work. You know, once we’re in the meetings and meeting the people and all of that, that’s what absolutely makes it work. The flying and the rest of it is, like, getting old.
Well, I know that when I was a kid, actually, that I remember you actually crying on the plane, when we flew. So, have you gotten over your fear of flying a little bit, though?
I had an epiphany on a flight, probably 25 years ago. I was terrified of flying. I knew I was – would die every time I went on an airplane. So, I had all my – my Will, everything, my paperwork was organized on the desk. I was ready to die, every time we went on a trip.
[laughs] My gosh.
Then, one time I was flying, and we’d kinda been delayed. I was by myself, which is also difficult. And so, I was flying, and I was looking out the window, and we were a little delayed out of Denver, and I was flying to San Antonio to visit my sister. And I looked out the window. There were the most incredible clouds, just billowing. It was the most beautiful sight I had seen, and I thought, ‘I’m okay.’ And from that moment on – plus, I love birds. Birds love airports. So, therefore, I am – I do a lot better. I don’t cry anymore. [laughs]
[laughs] What do you --
But she did used to cry, and not only did she cry --
-- oh, I remember, every flight.
-- she’s white knuckles.
I mean, I would actually start getting a little teary, just seeing her cry.
[laughs] I do much better now.
[laughs] What do you think about the idea of retirement? Do you think you and Dad will ever retire?
[sighs] That’s a hard one. I don’t think he thinks he works. And I think I do work. So, I keep trying to figure out how to do what I do as part of our picture, without working quite so hard. So, I’ve been working on that and cutting back a little bit during the week and not working as many days. But we both like what we do. You know, as much as I would like to go out and do some gardening or read a book or something, I do enjoy the management of our lives. And so [laughs] –
She does [whispering].
-- [laughs] I do. And so, I’m not sure about the retirement thing. I think at some point, we will definitely do less of everything.
Well, you’ve announced that pretty much every year. ‘We’re doing a little bit less.’
And I don’t really [laughs] notice it, so much. [laughs]
I know. Then we get to the end of that year, and it’s like, ‘Mm, I don’t know. It didn’t really happen.’
So, it’s day to day.
Okay. And the last question I have for you is, where would you wanna live, if you didn’t live in Santa Barbara?
I love four seasons. I still miss ‘em. I’ve often --
You wanna live at the Four Seasons? [laughs]
-- [laughs] yeah.
Yes. In four seasons. I grew up in Michigan, and I – to this day, I still miss the four seasons, seeing the changing colors and the spring and – you know, the hot summer. And you don’t need snow – that much snow, but I really miss that. So, if we didn’t live in Santa Barbara, which I’m gonna stay here until my family all agrees to go with me somewhere else.
Right. Because actually I think I missed this question. What do you think about living in the same city as your two daughters and all of your grandkids?
Number one. That is the best. We are so blessed to have that in our lives. I mean, a lot of people don’t have that, and we are so blessed to have that every single day.
[laughs] Okay. [Background music playing] Well, that’s our show for today. Thank you, Phyllis, Mom, for telling us what you think and giving us your insight. And thanks, Dad. Thanks to me, too. [laughs] Thanks to everybody. That’s our show. [Music playing]
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Comparisons & NSRCT
Chelator vs NaOCl and Managing Type I Transportations
Special Guest Presentation
Dr. Marco Martignoni on Modern Restoration Techniques
International Community & Surgery
Breaking Language Barriers & MB Root Considerations
ProTaper Ultimate Q&A and Flying a Kite
Rising to the Challenge
Working with Family & Managing an Irregular Glide Path
Controversy... Or Not
Is the Endodontic Triad Dead or Stuck on Semantics?
Zoom with Dr. Sonia Chopra and ProTaper Ultimate Q&A, Part 2
Carrier-Based Obturation Removal and MTA vs Calcium Hydroxide
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The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.