Cliff Ruddle Shares His Candid Opinions on the GentleWave 3D Disinfection Technology and its Associated Controversies...
3D Disinfection GentleWave Update and Intracanal Reagents
This show opens with an ethical discussion of the recent baseball cheating scandal and its effect on the sports world. Ruddle then presents some surprising news you may want to know in an update on the GentleWave controversy. Further, intracanal reagents are discussed in terms of what, when, and how long. Stay tuned for some philosophical wisdom in the wrap-up, which will take the form of ancient Chinese proverbs!
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Supply List - Ruddle on SHAPE•CLEAN•PACK
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: Baseball Cheating Scandal
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. Today on our show, we’re going to give you an update on what’s going on with GentleWave. And after that, my dad’s going to give you a presentation on intracanal reagents. He’s going to talk about what he uses, when, for how long, that kind of thing. But first, we’re going to talk about something that’s really big in the news right now, and it’s the baseball cheating scandal. So, why don’t you just bring us up to date a little bit on what’s happening with that?
Well, before I talk about the baseball cheating scandal, we first have to manage the hat scandal.
Oh, the baseball hat scandal.
Yeah. There’s a hat scandal.
There was another episode that we shot, some weeks ago, and I was up in the hills with you. You had taken me on a mountain hike, and I was wearing, in fact --
A Yankees hat. Okay.
-- my Yankee hat. And so, a colleague – a colleague --
-- an endodontist, a great friend, fabulous clinician, David Landwehr, Dr. David Landwehr – Dr. David Landwehr would be over here. He saw that Yankee hat on, and so, he sends me a text message, and he says, “Great show. The family’s looking really good. You’re filling a big niche in our profession.” And I’m going, “Oh, good! I think we’re doin’ a good job.” And then, it goes on, ‘But’ --
-- and I’m going, ‘But?’ Oh, we need to get better! He said, “But in a recent episode, I noticed that you were wearing a Yankee cap.” And he said, “I thought you were a lifelong Dodger.” So, I just wanted to say that I am a lifelong Dodger, and the reason I’m a Dodger --
[laughs] As you’re wearing the Yankees hat [laughs].
-- because – well, I may – you know, it’s a problem. When I was a little kid, like six years old, I was a New York Yankee, had been one all my life. If these guys play these guys, I always want these guys to win. But these guys are 100 miles south, we have gone to many games, and we have watched our Dodgers, and we have fallen in love with them, but not when they play the Yankees. So, David – okay?
Okay? All right. Oh, cheating scandal! Well, as you know, we’re at the time of spring training. All the clubs are down in Florida. They’re in either the Grapefruit League, or they’re in Arizona, the Cactus League. And there’s a lot of discussion, because Manfred, the Commissioner of Baseball, has been investigating the Houston Astros, who won the 2017 World Series against --
And that was a seven-game series – that went the full seven games, right?
-- that went seven games.
Yeah. I remember watching that as a fan.
So, I’m identifying the teams in the scandal. Why don’t you tell just a little bit about what that – the essence was.
Well, apparently, there was some sign stealing. So, they were stealing the signs that the catcher was giving to the pitcher, telling what pitch to throw. And I guess there was a camera out in center field that could see --
-- the signs, and then, they were maybe hitting trash cans, to notify the batters, what pitch was coming. It seems very convoluted, and I think that there was even talk that maybe certain players might’ve been wired. But they’re still doing – they’re still investigating.
So, when we found this out, that they had cheated, and then, knowing – being a Dodgers fan, and how they lost in the seventh game, you know – and I do remember, you know, watching the Astros hit a lot and thinking, like, “What the Hell!’ you know. So, anyway, it was just disappointing, because then, you’re wondering, “Well, wow! They’re gonna be punished”, right? They’re gonna have their title stripped, their World Series title. But so far, that hasn’t happened.
Well, this is the essence of what made the scandal go from, like, a little story, to, like, a massive inferno. And that’s because players initially denied it, had – you know, even thought it was investigated by baseball, and they had hard-core evidence, the initial was the line, “No, we didn’t do it.” Well, finally, the whole thing broke. So, what has caused outrage is, the punishment seems to not fit the crime.
Let me go back to 1919, when there was a World Series scandal between the Cincinnati Reds and the Chicago White Sox. And it was so defamed, baseball between known as the “Black Sox Scandal”. Baseball was so concerned that they hired a guy named Kennesaw Mountain Landis, a federal judge. They wanted to get a really tough judge in there, to clean up baseball, so we could have the purity of our game back.
I guess the White Sox threw the game or something, the World Series?
They – the White Sox threw it. The investigation ended with eight players being banned for life, and there’s a famous story. I won’t tell it, but it was on – Shoeless Joe Jackson got banned for life. He was the only player who did not cheat. So, anyway, when baseball today, come to the present, when we’ve noticed, you know, these punishments from the past and in other sports, I might add, stripping of medals and stuff, we were kind of surprised that there was a $5 million fine. There was firing of the General Manager, the Bench Manager on the – in the bench, and that was – and maybe some draft choices --
And I think all the players got immunity.
-- and the players got immunity in exchange for telling the entire story. That’s infuriated players.
The – this would take longer to explain, but it’s altered careers. People that got shelved because they knew which pitch was coming, some of those people aren’t in the game anymore. Some got traded. It changed careers. So, I guess what upset me about it is, I always think about our profession, and I always think about how we really long to have ethics and, you know, honesty, integrity. And baseball needs that, too. So, it’ll be interesting to see what happens because now, the Boston Red Sox are being investigated because some of the players from Houston, the Manager of Houston was fired, and he went to become the Boston Red Sox Manager.
So, he was fired, and now, they’re investigating, I think, even maybe the New York Mets, because they had to fire Beltran. He was also involved in that scandal. So, players come and go, and they move. So, all of a sudden, you have a lot of players in – on other teams, today, and they’re speaking quite freely about what they did. It was pretty sophisticated.
Yeah. I think it was disappointing enough to find out that there was cheating and that the punishment didn’t really seem appropriate, like it seemed like their title should be stripped. But then, when the Astros came on, I – I think about a week ago or something, and they came on to give their – issue an apology, and --
-- you know, they could’ve actually put this whole thing, like – you know, thrown some water on the hot coals or something, if they would’ve done it correctly. But they basically came on camera and did not really seem very sorry and basically said that it didn’t really impact the game, their cheating. It was just minor cheating. It didn’t really impact the game, and, you know, didn’t really seem very sorry about it.
And other players have even come up and say, you know, “Shame on the person who told”, you know, like – but I think, in this day and age, we don’t really look at someone who exposes cheating in sports and thinks, “Wow! What a snitch!” You know? I think that we actually want to know. As fans, we want the game to be fair. So, it was just kind of awful, when they come on and seemed really not sorry, because, you know, if you make a mistake, you want – you know, you want that person to own it, that – and be responsible for their behavior. So, that was just discouraging.
I think society loves second chances, and I think society historically, at least in the United States, we’re famous of taking the downtrodden, people have made mistakes, criminal behavior, if there’s genuine remorse and sorry, and there’s maybe been some penalty that was appropriate, we all tend to wanna forgive, give ‘em a round of applause, help ‘em to their feet, and let ‘em go. So, I think the outrage here is all the denials and not accepting responsibility.
Okay. Well, that – it raises a lot of ethical questions. And I actually will carry that into our next segment, because there’s also some ethical issues that we’re going to discuss, regarding GentleWave.
SEGMENT 1: Update – GentleWave
So today on our show, we’re going to talk about the ongoing GentleWave saga. Earlier this year, we talked about the problems associated with GentleWave, and some of those included patients having bleeding issues and really bad post-op pain. Additionally, Sonendo’s marketing of GentleWave has been controversial and divisive among endodontists. That said, now, even more ethical issues have come to light that we want to report. But first, can you just briefly remind us, what are the clinical problems associated with using GentleWave?
Sure. And you probably already hit the two biggest ones. So, I will just repeat it. We continue, ongoing, to get emails in the office. I look at discussion forums. Bleeding is still an issue. I’ll talk about what they’re doing to mitigate that. And then, of course, the post-operative pain. But the shape-shifting issue is another problem. We have Sonendo’s – they have an advocacy group, and they have some very learned people. And I won’t mention names, because some of them are my friends, but I’ve been a little bit disappointed in how they dove into the pool, headfirst, and didn’t notice there was no water. Hmm.
[laughs] Explain that, what you mean by that.
Well, we have a guy, an academician, and he is now giving courses – we’ll go into this a little bit later, the context, and who he’s partnering with. But he’s giving courses on the Triad, shaping canals, cleaning root canal systems, and filling root canal systems. So, he's now saying that we probably aren’t going to be doing any more instrumentation, and we have simplified the Triad, just to cleaning and filling root canal systems.
That gets me to my last point, the shape shifting. We’re – they’re all over the place. And you have a new technology, you need to have an international protocol that has been – that science has validated. It isn’t like you, out in left field, you know, “I’m doing my thing, and I’m reporting”, and somebody else is reporting. We need to have multiple universities collaborating, good, scientific protocol. So, to recommend no instrumentation -- and that’ll be even more alarming to the audience, when you get a little later into this segment, and you ask me some more questions.
But right now, I would say, filling root canal systems, they have no solution for that. A single cone and a BC sealer that’s immiscible in any solvent, and cannot be removed completely mechanically, is completely bankrupt. So, to advocate, “We’re not instrumenting anymore”, great! Maybe you can even clean it perfectly. But show me how you fill root canal systems on a predictable basis.
So, these issues were being discussed pretty openly on the AAE discussion forum, which is called “The AAE Connection”, and also – pro-GentleWave advocates were also saying things on the discussion, things like, “It’s the new standard of care”, and “If you don’t refer to an endodontist who uses GentleWave, you could be facing a class-action lawsuit.” So, there was a lot of controversy on this discussion forum, and so, then, the AAE just removed it. It was just removed, right?
Yeah. Well, you know, the AAE is in my doghouse. I’ve been a member since I graduated from Harvard University in 1976. So, I think there’s a lot of value to being an AAE member, historically. I think, right now, they have their thumb on the scale, and they are choosing winners and losers. And that is not their role.
Well, when you pay your membership dues to the AAE, one of the things that you get is, you get to be part of this discussion forum. So now, what is happening, since there’s no discussion forum? It’s been removed. Dr. Pannkuk, who was here last week, what is – what is he doing?
Oh, Terry is a good guy. He’s sometimes misunderstood, but people don’t understand how passionate he is about the science and the whole protocol for clinical endodontics. So he cares enormously, and he is disgusted, because by taking down this forum, they’re not allowing members to exchange ideas. This is the most fundamental thing in a democracy.
Socrates would probably roll over in his grave. So, you don’t like what you’re hearing? Take down the discussion forum, or whatever it’s called? So, Terry actually started a new website, where you can go, read a few words, and then, if you agree, you can sign. And what you’re signing to is, you do not like what the AAE has done. And Terry has called that “Reconnection”.
“The AAE Reconnection”?
“The AAE Reconnection”. And Terry has over 100 people that have signed up, in a very, very short period of time. There are hundreds and hundreds of really angry endodontists. So, Sonendo can keep doing their little marketing stunts, but it’s not winning over the hearts and minds.
Well, why would they take down the discussion forum? Like, what’s the – what’s the latest, now?
Well, I don’t want to get into politics today, but you could even argue, it sounds like a quid pro quo. Because why am I pardoning – if I’m the AAE, why am I pardoning with a company, and they’re giving --
So, that’s what it is. They’re partnering with --
-- yeah. What is it called?
Oh, they’re giving these “To-The-Point” webinars. That’s the name of it. The AAE has “To-The-Point” webinars, and they have somehow collaborated, partnered, some kind of a relationship, where they’re giving courses – they are quick to say at the bottom, “We don’t necessarily endorse what the speaker says.” The problem is, they’re – our membership organization is giving a platform and promoting something, and they’ve never done that, historically.
And they’re also, now – I guess Sonendo is now marketing to GPs. Is that correct?
Well, they would say steadfastly, they’re not. And again, we could have – we’ll be doing updates. So, don’t worry. They’ll be lots of ongoing wave – just like Coronavirus, we’re hearing about it every day, because – this’ll be released in a while. But right now, it’s February. So, you know, last week, I said there were what, 25,000 cases? And this morning, there was 78,000 cases. So, things change. So, there’ll be updates on GentleWave.
But back to GentleWave. Yes, the AAE is collaborating with Sonendo to give these courses, and they’ve never done that before. They’ve never chosen sides. A professional organization is to put people with diverse opinions – it’s fine to have diverse opinions, to come from completely different ideas. But we do it at the AAE Annual Meeting, there’s point-counterpoints, and everybody has a chance to say their concerns and their joys and hopes for the new technology. But when you give a forum, and you start trottin’ people out, and now, they can go out to a lot of houses, we lost a connection.
So now, we can’t talk to each other about it. Because, let’s be honest, busy people. They go to work early, they come home late. Where do you talk to all your pals? You might have 3, 4, 5, 10 friends you talk to a little bit, but “The Connection” was a chance for all endodontists, academicians, to get on and discuss back and forth. And even if it gets a little unpleasant, if it gets a little bit nasty, I think the AAE should’ve stood back a little bit. If you gotta pull down something to kinda have it be civil – civil discourse, fine. But it was really heavy handed to take it down and not even to reopen it. There’s no plans to reopen it.
It seems, like, ethically problematic, just – when you think of – at – like, the AAE’s supposed to be like an educational organization. Partnering with a commercial company that sells a product, that just seems like it doesn’t – it’s not a good match. I mean, it seems against their – I saw on their website, one of their core values is collegiality, which they define as “a friendly and inclusive professional culture, characterized by fellowship and respect” and that they really want to emphasize diversity and inclusiveness.
But it seems like they’re really operating in a way that is contradictory to what they even have on their website.
So, I’ll make a prediction. This might not happen, but if the AAE continues to behave like this, we’re going to have another massive division. You might recall the American Dental Association, ADA, known worldwide. There was so much disgust by commercialization from the ADA that a large group, 60,000 dentists, splintered off from the American Dental Association and they formed the Academy of General Dentists, the AGD. So, there are so many endodontists that contact me on a daily basis, that are so angry about our association and the heavy-handedness towards this technology. When they see the members are doing this, they should step back and go, “Wait a minute! We’re supposed to be inclusive, not divisive!”
I also saw, regarding, like, the claims that GentleWave might be the new standard of care, I did see on the AAE website that their mission is to be dedicated to the higher – highest standards of excellence in endodontic care. So I am aware, actually, of a past example, and maybe you can tell us about it, where the AAE embraced the microscope as essential, back in – in 1995. Tell us about that meeting that you were at.
Well, to tie this into our current things, we have new technology. It’s GentleWave. A company has a commercial product, so, round of applause. There are so many new products each year, not to mention the last three or four decades, it’s staggering. So, back in 1995, the AAE wanted to know more about microscopes, because microscopes weren’t prevalent at that – in that era. Recall, I got my first microscope from Noah Chivian, who was selling the Chayes Virginia Dentiscope, and I got that in ’87, ’88, in there. And the first guys were Apotheker and Jako, and they, in – a decade earlier, had first reported the use of the microscope.
So, as some of us early adopters and pioneers started using the microscope, word began to spread. I was giving courses, and guys were coming in from all over the country. We had women, guys coming from around the world, actually. And so, the AAE was getting word of what Carr was doing, Gary Carr, Syngcuk Kim, and Richard Rubinstein, and myself. So they said, “Let’s have a class in Chicago for the Chairs of North America.” So, in 1995, at the O’Hare Airport in Chicago, they had a 3-day symposium, called “Introduction to Microscopes, an Endodontic Workshop”. It was effectually just called “Teach the Teachers”.
I was one of the four speakers, Gary Carr, Syngcuk Kim, Richard Rubinstein, and Ruddle. And we gave three days of everything you could do with a microscope, from massive pathologies to microsurgery to flaps to retreatment surgery, getting – blah, blah, blah. At the end of three day, the Chairs – it was the first time they ever had 51 Chairs under one roof, they voted 51 to 0 that all programs in the United States would implement the microscope into the teaching program the following year, ’96, so that all students, by 1998, would graduate with some proficiency in the microscope.
So, what was interesting to this point, now, is, all the microscope companies were also invited. So, we had this symposium on microscopes, but back in the back, you know, Seiler, there was – there was a Dentiscope, there was Global, there was Zeiss, there was Leica. There was all of these scope companies in the back, and they were all part of the solution. The AAE did not say, “Let’s have Zeiss give workshops, and we’ll do ‘em with workshops. We’ll go around the country, and we’ll lecture on the Zeiss microscope.” No, the AAE was invested in vision, and vision is lighting and magnification. That’s what they voted on.
So, not picking a specific brand of microscope. And then, also, weren’t they very reluctant at that time to even declare that the – using a microscope was the new standard of care? I mean, they embraced it.
But it wasn’t actually called – they stopped short, calling it the new standard of care. Right?
Yeah. I have two opinions on this, and I wasn’t laughing at you. I was laughing --
-- at what I was thinking. Sorry, everybody. There’s a lot of things going on in Ruddle’s brain. Anyway – staggering. Actually, it’s just staggering, what I’m thinking. You know, when they were doing this microscope course, they wanted – they didn’t even tell the schools what scopes to put in. I mean, the schools’ biggest dilemma, at the end of the third day, when we were all talking now, as a big group, a big roundtable, the Chairs were wondering, “Well, who’s gonna buy the mounts? The students, coming in? The new grad students? Are they gonna buy those ceilings mounts, to hang the scopes? Or are we gonna provide scopes, and then, the company will come in – Zeiss’ll put it up, or Leica, or Global?”
So, nobody chose anything. They were there to encourage the nobility of doing better work. So, back to GentleWave, it’s fine to say, “It’s a new technology.” Let the people come in at the AAE, have them give courses. They can do workshops. That’s done with every new technology. But we don’t see them giving special courses, and that’s the only course, and it’s a co-sponsor between a company and the AAE. That’s causing a lot of outrage.
It seems like – that the AAE would agree that canals need to be 3D disinfected. But that is a standard of care, to remove the bacteria. But, you know, there’s other ways to 3D disinfect, besides GentleWave. And there’s – and you can get the same results as GentleWave. So, it seems odd to kinda be aligning yourself with a certain, very expensive product, when there already exists technology to 3D clean a canal.
You’re probably telling the world right now what the world doesn’t know. So, you’re seeing it pretty easily.
Because if you listen to Sonendo, they’re the only company in the world that can clean a root canal system. So, when you said so easily that there are other methods available to help colleagues reach that noble goal, that is absolutely true. So, when we hear these claims, “You can do one-visit endodontics. You get faster healing. You can get your first lateral canal”, well, some of us have been doing it for 45, 50 years. And before me, there was others that had done it for decades.
So, this standard-of-care thing and a microscope, it's interesting you said that. There was a lot of anger, because back in that era, the endodontists that were starting to embrace it then, and then, as it become integrated into the teaching programs, it just took off. All new dentists just grew up using the microscope. You would’ve thought they would’ve said, “That’s the standard of care”, wouldn’t you? But they didn’t. They were so careful. “Oh, no! We can’t call it the standard of care, because what if you don’t use a microscope, and you’re an endodontist?” Okay? Well, then, you look really bad. You’re practicing below the standard of care.
So, they would never take that position with the microscope, but it seems like they’re trying to implicate that this might be the standard of care. To me, GentleWave isn’t good, it isn’t bad, it just is. It’s just another adjunct – adjunct technology to help clinicians get a result. Okay? It’ll lead to something else.
It seems – it seems that by the AAE embracing GentleWave, that they’re actually kind of compromising the standard of care because of the problem that is going to come from trying to fill those so minimally-prepared and -cleaned canals. Like, how can you even fill them? It's almost like it’s a compromise to the standard of care.
So, here’s my analogy to you, because you’re my old pal.
So, the AAE is being really noble, “Let’s treat root canal systems” -- shh! They don’t know it, but it’s been done before [whispering].
But let’s do it now, because it’s never been done before! And so, now, they’re out on that – they’re up in that big tree. They have a saw. Imagine they have a saw. So, they’re up on a big limb that’s coming off the trunk of a tree, and they’re there, sawing the limb that they’re standing on, because they didn’t remember --
-- “Gee, we don’t have a predictable, three-dimensional way to fill a root canal system!” And now, when their gurus are saying, “No instrumentation”, Hell, if you wanna look at their post-operative problems, it’s because the canals are too parallel!
If they had a little taper, a smooth-flowing, tapered shape, that would limit and restrict the reagents’ escaping to the PDL side. It would hold the gutta-percha in the root. They could actually warm the gutta-percha and mold it in. We can do this stuff in, like, 5, 10 minutes, on a molar. We can fill in three dimensions. So, anyway, I like the idea that GentleWave is trying to do something better. Let’s be very honest. I like that they can clean pretty darn well. That’s some of the emerging evidence. But many of us, thousands of us, have also been cleaning pretty well for four decades.
There was one other thing I had thought of, and it relates back to the censorship show we did, where we talked about the ADA having a new edict, going forward, starting at some point in the future, very soon, that you were – lecturers were – would not be allowed to even mention product names. So, this is kind of interesting that that’s the path that the ADA has taken, that you can’t even mention the commercial products, and then, here’s the AAE, actually partnering with a commercial product. So, it just seems a bit ironic.
Well, yeah. I mean, we heard that from Gordon Christensen. I’ve known Gordon for decades. He’s a really great guy. He’s loved around the world. And I was doinh a course in Provo with Phyllis, and Gordon was on his best behavior, because there was a Congress, and he had several hundred people there, and we were talking just before it started. And what he said was – I said, “You seem to be pretty irritated about something” And he said, “I am.” And he’s pretty connected at the ADA level and has been on Boards and stuff. He heard that two years or three, from last year, that the ADA will not allow any commercial product to ever be said by any speaker on stage. And that’s when the ADA dies. I just said that.
Because when people come to train with me, and they have, for 45 years, and we’ve had – I’ve trained tens of thousands of people, only because I’m really old, so, I’ve had time to get that done, but people wanna know what you do. They wanna know when you do it, how you do it, how you hold it, how it – what it looks like, what’s gonna happen, and if you can’t say, “WaveOne Gold”, or you can’t say “ProTaper”, or you can’t say “GT”, or you can’t say any of the files, “Vortex”, then, how does the dentist learn? You just have to say “file”. So, the ADA and the AAE, the parent – from what you’re telling me, they’re – you know, Yogi Berra said, “When you get to the Y in the road, take it.”
So, basically, you want the clinician to be able to say what they want to say and what they’re using. But we want the organization – the educational organizations to be a little more neutral.
I don’t know if I could close it any better than that. Your professional organizations are there as a service organization. They’re there to promote the specialty, and they’re there to be like a rising tide that raises all ships, not picking the winners and the losers.
Well, this news is a little concerning, and it kind of raises some more ethical issues, like the baseball cheating scandal does. But do you have any closing comments?
Mm. Well, maybe bring up the montage –
-- oh, it’s up. You know, I have my – my Multimedia Team, they’ve been doing this for years. So, there’s three across, three down. We must have 10 of these palettes, if not 1,000, of 9 each, 9, 9, 9. If you start to look at this, this was before the EndoActivator. So, I better say something about the EndoActivator. A lot of people might think, “He’s commercially involved! He has the EndoActivator! GentleWave! EndoActivator! That’s a problem!” No, it’s not a problem, at all.
You know? $500, you get the basic technology. For less than $2 a patient, you can move reagents everywhere. If we did a protocol with EndoActivator, as long as GentleWave does their protocol, we’d probably be cleaner than they are! And the thing I like about it is, this was before the EndoActivator. This is even when the shapes were a little bit bigger. Now, the shapes are a little bit smaller. The point is, we could show you palette after palette after palette, and I could also switch these all out, and just have cases by the international doctors, cases that we’ve treated.
These – we’ve taught. These doctors have gone home. They are delivering this treatment on a routine basis to their patients they serve. So, root canal systems -- if you’re wondering why we’re maybe a little animated today and a little passionate, it’s because it’s something that I was teaching in the ‘70s. It’s something I’ve taught my whole life. I’m surprised so many endodontists, even though more than 1,000 endodontists came to Santa Barbara seminars, where were the other ones, and why were they doing lateral condensation all those decades? And why were they throwing all the carrier-based obturator people under the bus? And now, suddenly, they want to treat root canal systems!
So, what I’m gonna say is, it’s taken a long time, but Schiller would be real happy, because suddenly, the whole world is starting to think that root canal systems are important. They’re strategic. And every portal of exit is a potential conduit for the egress of irritants. So, we can treat root canal systems. I want the general dentists watching this to know that, for about 70 cents a patient with reagents, for another $2 for a plastic polymer tip, you can do world-class work, and you didn’t do a $100 throw-away, disposable handpiece, and you didn’t invest $70,000 into the technology. So, I hope GentleWave keeps going, because I think they’re going to get better.
And the good news on the horizon is perhaps, as we know with any infancy and a new product, it will grow. They’ll address the bleeding things, I’m sure. They’ll probably get a protocol down for shaping. Suddenly, they’ll be able to fill root canal systems and not worry about over-extensions. We had our first case, you know, in the JOE last month, where we had a BC over-fill with a permanent paresthesia. And I’m not blaming necessarily the BC sealer, but these “stuff a cone down the root and hope like Hell everything works”, that’s not endodontics.
Okay. Outstanding presentation, actually, because I think we learned a lot. And it’s really good to know that systems have been being treated for a long time, now, and it’s just not a new thing. So, let’s go on to the next thing.
I actually have a lot more to say about GentleWave. I’m just getting started, but we’ll have to wait till next time.
Okay. Thank you. Thanks for watching.
SEGMENT 2: Intracanal Reagents
Today, I’d like to talk a little bit about intracanal irrigants. And of course, they’re always used in conjunction with manual or rotary files. But when you begin to look at what our assignment is, on the degenerated pulp, gangrene necrosis, egress of irritants, lesions of endodontic origin, then, it becomes obvious that our files aren’t going to be able to get into all of these recesses and nooks and crannies of the root canal system. So, we’re gonna have to talk a little bit about the reagents. And so, here we go.
If you look at the access and then, of course, we work files, we negotiate, and we reproduce manually the anatomical space, okay? So, you can begin to see that when that file is in the tooth initially, and it goes to length, we have almost no space, almost no space. We all remember the times in our lives where maybe you had a little bucket of water, and you stuck your fist in the water, your fist displaced a lot of the water. So, if you consider sodium hypochlorite in here, what little reagent is actually in the root, when you put the file in, it displaces what little reagent was there, and we’re virtually working in a dry environment.
So, the secret might be to think about a viscous chelator. When I say, a viscous chelator, I’m thinking of something like RC-Prep, Prolube or Glyde. That’s all ethylenediaminetetraacetic acid in a methylcellulose suspension. So, there’s a lot of benefits that I’ll talk about just a little bit more. So, to go ahead with our story, we’re going to need certain reagents early. We’re gonna need certain reagents later, because when we think of sodium hypochlorite and how it dissociates into the OCL, when it dissociates into the OCL ion, that’s the activity that we’re looking for, to work away from the shape of the canal.
So, shaping facilitates to give us a critical reservoir of irrigant, and it’s that reservoir of irrigant that can be reacted. It can be activated, and it can egress, penetrate, circulate, and digest tissue from all aspects of the root canal system. So, isn’t it starting to sound like it’s possible? We don’t have to do all this work and all these clever moves. We just have to treat the trunk of the tree, and our reagents will work out into the limbs of the tree. Okay. So, we’ll go ahead a little bit more. Cleaned root canal systems can be filled. So, the whole key is, think about the reagents again. Remember Newton’s Laws of Physics. Only one mass can occupy the same space at the same time.
So, this means that if we’ve left plugs of tissue in this lateral anatomy, there’s no way we’re going to move obturation materials into occluded space. So, we have to remove everything, like the extraction. Okay. Let’s continue a little bit more. I know many of you are interested in new ideas with cleaning root canal systems. There’s a lot of devices that have come on the market in the last few years. Of course, the one that’s getting all the noise now, we talked about in an earlier segment, was GentleWave. This was all done before GentleWave.
This is another palette of nine images. Sometimes you’ve seen me around the world, giving lectures, and I like to show the collage. We have thousands of images that we could show, thousands from me, and thousands from you. They come in from all over the world. But the neat thing about what you see in all these cases is, you see trifidity, you see bifidity on one branch, you see trifidity. Look at this. Look at this! This is endodontics. Do you think you’re gonna put your files into all those little tributaries? I don’t think so. Ruddle would never be able to do that, even on his best day.
So, you know, the anatomy is ubiquitous, and you can see loops, bifidities, crestal canals, sub-crestal canals, root canal systems. That’s why we exist, when we’re doing endodontics, to serve our patients by treating root canal systems. So, in essence, if we go ahead, this isn’t gonna be a little lesson today on the vertical extent of treatment. But it also has to do with our reagents. A lot of people were trained in different ways, but I’ve taught for years the importance of pre-enlargement. If we can get this space opened up early, and if we use a viscous chelator, like RC-Prep, Glyde, or Prolube, we can now have our file buttered, as it goes through the body.
And when it gets into the curvature, the flutes will be loaded with a really important reagent. That reagent can what? Well, it can begin to immediately lubricate the file, to help the file slide through delicate micro-curvature. The other thing we can get from it is, when we stick a file into vital tissue – remember, vital tissue is collagenous. And that’s like glue. In fact, industry for decades made glue, like Elmer’s Glue, it was harvested from the hoof of a horse, which is rich in collagen. So, a viscous chelator, then, not only lubricates our file, but it prevents the re-adherence of vital tissue. When you pull a file out of vital tissue, the tissue re-adheres to itself. This means, there’s no pilot hole to place the instrument.
So, if you can prevent the re-adherence of tissue now, we have a pilot hole, and we can work instruments through that space, to get to length. The final thing is our files are making debris. So, when our files make debris, they’re more effectively suspended. So, if they’re suspended, it’s loose debris, not compacted debris. You want your debris to be loose, so it can be floated out of the tooth and liberated from the root canal space. Little tiny things that make a big difference! Well, we’ve been having big talks over here about, where do you work to? What’s working length? Where do we work to? Everybody said, “Work to the cemental-dentinal junction.”
Well, it varies from tooth to tooth. It varies from root to root. And it varies from wall to wall, in a single canal. So, it’s an – a landmark that all histologists can identify, but it does not convert to the clinician, chairside. You have no idea where the CDJ is. You could say, “I’m gonna work to here. Oh, maybe I’ll carry it to here. Maybe I can carry it to here.” So, the blue is the cementum. The cementum goes through the apical foramen. It migrates up anywhere from a few microns, to many millimeters. So, think about that.
So, let’s look at our challenges with our reagents and get back to that. So, let’s be careful about this. Of course, I’m gonna advocate working to the terminus. I’m gonna advocate that. Isn’t this fun, how I’m moving this back and forth? It’s just the flow of the roots in my mind, how they work. But let’s go ahead, and let’s look at this, and look at the pulp, now. So, let’s pretend – cycle drama role play – this is a vital pulp. We have collagenous tissue. And let’s get going. As you’re working those files down, I’m advocating the pulp chamber is brim full with a viscous chelator. Lubrication, emulsification, flotation. I just said it different, but you’ll get it, and we’ll learn.
As these files go through, they’re cutting. As they go towards length, they’re trimming off dentin, each in their own way. Oh, a beautiful rip! We’re tearing! Now, we have a cocktail! Hey! Inside here, we have dentinal mud! We have pulp tissue and maybe even bacteria! So, we have a great cocktail, and we need to have a lubricant, so we can catheterize the canal and not obstruct the canal. Okay. So, you can see all this mud. Many of us push it inadvertently into empty space, where there used to be a little tissue. We push it ahead of the file. All these serve to sabotage our clinical efforts.
Remember, it’s supposed to be fun! We’re supposed to be in charge! So, I want you in charge by using viscous chelators early, until you have secured the canal. When that canal is secured, get into the sodium hypochlorite regimen immediately. Okay. So, here we go again. Let’s not stop our work up in here. Let’s stop our work pretty much at the radiographic terminus. So, if we take a picture, radiographically, on the x-ray, we’d like to see the file arrive right at the terminus. You’ll see your apex locator begin to illuminate on the digital read-out, and you’ll be seeing those bars fill in. And a lot of you like to work one millimeter short or a half a millimeter short. I’m working right to apex. I’m working right to apex, okay?
And that means I’m on the edge of the root. Hey, listen! I want you to know that I know. If you extract the tooth, we’re gonna see a little bit of a file, sticking through the root. We’re patent! Say, “patent”! Can you even spell it?! P-A-T- -- I can’t remember. Patent! So, that’s an important concept, to work canals to their full length, because why? We want the irrigants to come off the body of a canal, to work not only into the lateral anatomy, but into the tubules. We have a lot of tubules! Okay? So, we wanna clean out tubules. And we can penetrate and get our irrigants back, somewhere around 100 to 400 microns. Okay. How about that!
Let’s take some of these principles and concepts to an actual case. Notice the second molar. It’s a bridge abutment, in the most funereal sense. Notice that we have, you might be able to see it, here, a little furcal lesion. I guess you can probably start to notice that we have pretty close root in proximity to the neurovascular bundle. And then, you can probably see multi-planar re-curvature. So, tight, restrictive places are gonna require that we perfectly follow the intracanal reagent. So, remember, what do we do immediately first?
Well, after you take the bridge off, in this case, and go ahead and begin working, we use a viscous chelator. The viscous chelator, again, I’m gonna say over and over, it gives us a superior lubrication. It emulsifies vital, collagenous tissue, so we maintain the pilot hole. And it keeps debris up in suspension. Notice we’re not forcing these files. We’re feeling delicately, trying to manually reproduce the anatomical pathway. When you get that little stick, you work that file with the viscous chelator. And every time you lift the file up, you’re letting some chelator run into the vacated space. You’re also re-buttering your file.
So, when you go back into that space, you’re carrying new reagent into that last, little millimeter. And we work that 8 until it’s loose. A loose 8 will accommodate a 10, and a loose 10 is already almost a 15 file. So, we have a super glide path. Okay. So, if we take a radiograph, you can see, we’ve negotiated the canals nicely. I was probably thinking there might be something over here. I couldn’t reproduce it, but I wanna bring you back to the importance of early pre-enlargement. Notice all this space in here. That allows the file to be pre-curved, in your hand. It puts more reagent in here, and more reagent means more forgiveness and a better chance of carrying viscous chelator into the apical one-third. The pack is the thrill of the fill.
Many people we’ve trained over decades to treat root canal systems know GentleWave. This is before the EndoActivator. But you can notice here, we have a big furcal canal. We have three apical portals of exit. Ruddle was only putting instruments into this branch. And of course, we have some bifidity here. So, this is endodontics! Put the bridge abutment back on, provisionalize it, and let the general dentist, in this case, definitively place the bridge. So, a little bit about the reagents. We’ll keep going.
Let’s review. So, when we have a vital pulp, maybe even a necrotic pulp, because sometimes it is [makes loud sniffing sounds] stinky in the pulp chamber, but, you know, counter-collagenous tissue, even bleeding tissue deeper. So, probably we should be thinking about a viscous chelator. Well, once we’ve negotiated the canal, redundancy’s the mother of excellence, I just told you this. Then, we would go to sodium hypochlorite. And sodium hypochlorite would be ran at about six percent. And then once we got our shape, we would wanna be using EDTA, 17 percent, because that’ll remove the smear layer. The byproduct of the instruments’ working is mud. The fatal flaw in clinical endodontics is dentine mud.
So, the smear layer serves to remove the mud from the lateral walls, circumferentially. That opens up the lateral anatomy. Now, we come back in with sodium hypochlorite. And now, it will penetrate! The sodium hypochlorite will digest! It will circulate! And when it’s agitated, it’ll move into all aspects of the root canal system. This is what allows us to fill root canal systems. It’s kind of amusing, watching some of these GentleWave people struggle with filling. Many of my friends were filling root canal systems routinely. Now, they’re having troubles filling root canal systems, because their preps are so small, they can’t get their stuff in. And don’t think single cone and BC sealer is the ticket. We’ll talk about that more, later. So, marvelous, marvelous, marvelous repair material! Marvelous!
So, in closing, when you’re working in a canal, and it’s very tight, it’s torturous, longer ones, narrower ones, and more curved ones, this is when exactly you need to use a viscous chelator to butter the file, keep it lubricated, keep your debris in suspension, and emulsify tissue. And if you do that, good things happen. And of course, once you have your patent canal, and you have your working length, and you have a through-and-through opening that’s completely catheterized, then, we can go on. And of course, we wanna go to rotary reciprocation, mechanical. We wanna do that in any event. Why? Because it’s very, very efficient with time.
The other thing is, if we can shape and get a quick shape, guess what? Once again, we’re gonna be able to get all this restrictive dentin out of here, and by removing restrictive dentin, guess what? A bigger volume of reagent! That means more capacity to penetrate, circulate, and digest tissue. So, here we are, coming in with a little probe lighter. I’m gonna talk about this more, later. This is just a shaping file. Just cover this up. It could be anything you can imagine, doesn’t matter! It’s rapidly making shape. Shape facilitates cleaning! Shaping facilitates filling root canal systems.
One thing some of these people are having accidents should recall, when you’re almost doing no instrumentation, notice how parallel this is. When this is parallel, it’s easy for reagents to go either way. And when – oh, I gotta stop this! You know, this is – this is really important stuff. You’ve read in the literature, for decades that you can only irrigate about one millimeter apical to your cannula. I’m goong to show you that in a catheterized canal you can bump your reagents six, eight -- okay. You can bump your reagents many, many millimeters. And notice, I don’t have to get the cannula so close to length.
So, good things happen when you stay away from length! Less post-operative problems, less sodium hypochlorite accidents. And if you learn a little thing that I’m gonna show you on another segment, for 25 cents – I know that’s overwhelming, it’s a massive number, well, you can bump your solutions – again, to be redundant, 6 to 8 millimeters, and the cannula stays away from length. It stays up higher, and that’s a good thing. Okay. Boy, this is really fun. You’re getting to learn some stuff. You’re probably going, “Well, how does he bump those solutions? Irrigate, vacuum, irrigate” – hey, that’s why you have to come back to “The Ruddle Show”. Hell, you think I’m gonna give you all my tricks, in one show?! Come on!
Well, let’s get this outta here, and let’s go on. And let’s go on. You’ll see this again. But one last thing about reagents. So, we’ve identified, early, viscous chelators. We’ve said sodium hypochlorite during all of the shaping activity. We’ve said, at the end, remove the smear layer. Well, if you can agitate, listen! Almost 90,000 people internationally are using the EndoActivator. Model success! Success leaves clues! They’re getting root canal systems! And each disposable tip is less than $2 U.S. Why would you do $100 handpiece, $70,000 technology, when you can – listen! Liquids fracture. At the fracture interface, bubbles expand. They’re unstable because of heat and pressure. Every single one bubble that implodes sends out 40,000 shockwaves. And you get lifting of bacterial mats, biofilms break free, rods and cocci are flushed out! Okay?
So, this is a thing of joy. Anybody can treat a root canal system, if you know how to use your intracanal reagents, and you have a couple little ideas. So, I’d like you to consider some technology that’s affordable. And one last thing about the EndoActivator. We’re gonna have a bunch on it, because we have 19 peer-reviewed papers, so we have to investigate this much deeper. But the EndoActivator can be used at any time, during the 9-inning baseball game, during the 60 minutes of football! You can use the EndoActivator pick-up. You don’t have to build platforms!
So, one last case, just got this one last week. This is so cool! You know, Howie, we call him affectionately, “Howie”, he’s a Canadian endodontist. And he said to me in a little email, and I’m paraphrasing – because Howie might be watching, but I hope, Howie, you’re really proud. He said to me, “Cliff, I don’t know what all the discussion, all the drama [with emphasis] in the marketplace!” He said, “I did this, last patient of the day, took me about an hour.” He said, “I used what?” He used ProTaper Gold, the EndoActivator, and I wanna just show something.
You see a very long loop, right here, little loop, little loop. There’s an exit, exit. I’m gonna get this outta here. I’m covering up the work. There’s probably one, two, bifidity, three, four, and this one would be five, five portals of exit on a really simple, single root. Okay, everybody? Enjoy your intracanal reagents, realize you’re never gonna do it with your files. Files don’t clean anything. All’s they do is make a pathway that holds a critical reservoir of sodium hypochlorite and whatever else. You really don’t need to use final rinse solutions. I told you the 3 reagents I’m using: viscous chelators, sodium hypochlorite, 6 percent, 17 percent EDTA. That will clean everything.
I have done the research. I did it back when I was a resident at Harvard University. I did it with Z. Skobe, and we did SEM’s, and we showed clean root canal systems, as we did it, in that era. Thank you very much.
CLOSE: Philosophical Wisdom – Chinese Proverbs
We’re gonna close our show today with a segment we call “Philosophical Wisdom”. And today, this will take the form of Chinese proverbs. So, I’m going to read a couple quotes, one which is attributed to Confucius, to my dad, and he’s gonna tell us what he thinks about that, what it reminds him of. So, the first one is, ‘”To know the road ahead, ask those returning.”
Well, for all those young GentleWave aspiring endodontists, before they go out and make their first purpose – purchase, maybe they should just look at some of those people coming back that have done it, and they might find out they would run into some of the people that have been doing it for 40, 50 years. And they might be able to find out, there’s lots of ways to treat root canal systems.
Okay. That’s good. And the next one, “Success depends upon previous preparation, and without such preparation, there is sure to be failure.”
Was Confucius an endodontist?
Kinda seems like it [laughs].
He’s talking about the importance of preparation?
Was he talking about deep shape? [laughs] Well, I think Confucius had it right, you know, if you’re not preparing in the word of “getting organized”, and if you’re not preparing in terms of shaping, then, we’re not gonna have the same level of success. Because shaping facilitates cleaning and shaping facilitates filling root canal systems.
Okay. And then, let’s bring up our last graphic, which is “Crisis”. And this is – “crisis” in Chinese, is made up of two symbols – two Chinese symbols, and the first one means “danger” and the second one means “opportunity”. So, what does that make you think about?
Oh, I love that one. Because, in any crisis in life, maybe we can’t see it, even in tragedies, there’s always something in it that can be learned, that can make – take us on a go-forward basis towards greater success. I don’t want to be slapstick with our show and about the Coronavirus segment that we did last time, but the danger is getting it. And then, we don’t know the incubation times yet. We don’t know the epidemiology yet. We don’t know if it’s really a pandemic yet. But the opportunity is a vaccine. The opportunity is, have cleaner protocols, where we don’t have SARS, MERS, and Coronavirus, every few years, even influencing economics worldwide. That’s the opportunity, is to have better cleanliness, better protocols, and get a vaccine.
Yeah. I think that when you think about – when most of us think about some – any really bad experience that we’ve had in our life, that a – probably a lot of us would say we’re glad that happened to us, because how our path maybe changed, afterwards --
-- new opportunities that came, because of that. So, you know, it’s not – crisis is not just a bad thing. It – half of it’s bad, and then, half of it can actually take you to another level.
So, to – maybe my last remarks for this segment would be regarding danger and opportunity. And if we’re playin’ off this segment, again, I said, “GentleWave isn’t good, it isn’t bad, it just is.” So, the danger is, is the misinformation, the marketing scandalous behavior, and the claims that aren’t – are many times unfounded. But the opportunity is, we all know we need to do a little better job. So, it’ll drive a lot of innovation, and the opportunity is, I can tell you, in Q1, 2021, look out! We’re gonna have an affordable, as-good-as GentleWave.
Yeah. I do want to say one thing, because we were talking about the AAE a lot today. I actually think that that’s kind of in a state of crisis, right now. So, it will be interesting to see --
-- how the AAE changes and --
Makes it into an opportunity.
-- maybe makes it into an opportunity. So, that’s our show for today. Thanks for watching. See you next time.
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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.