What Your Local Dental Reps Can Do for You?
GPM & Local Dental Reps Glide Path Management & Best Utilizing Dental Reps
This episode opens with a frank discussion of scheduled maintenance power outages and the excitement they add to our lives. Ruddle then goes on to describe how to manually reproduce canals and perform mechanical GPM procedures. The next segment focuses on community interaction and the importance of maximizing your local dental representatives. The show closes with a return to Demotivators, which will cleverly motivate you with reverse psychology!
Related Materials & Show Notes
Much has changed in global endodontics over the past 40 years and a great deal of this change has been driven by the relentless introduction of new technology...
It is generally recognized that root canals can be predictably prepared when shaping files have a reproducible and sufficiently-sized pathway to follow. The secret to shaping success is glide path management (GPM)...
Many times over several decades I have described various concepts, strategies, and techniques for shaping root canals. Although the concepts and strategies have essentially remained the same, the techniques have evolved based on the technology available in any given era...
Cliffor J. Ruddle, DDS, examines why glide path management is the key to successfull endodontics...
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: Maintenance Power Outages
Welcome to the Ruddle Show. I'm Lisette and this is my dad Cliff Ruddle. Today on our show first my dad's going to give a presentation on mechanical glide path management, and after we're going to talk about how to maximize your interaction with your local dental reps. But first we want to talk about something that's affected our lives a lot lately; it's affected you too, right?
And that's these maintenance power outages that we're having. And right now I have two that are pending. I don't even need to open these – these are from Southern California Edison – I don't need to open these because I already know because they also send me emails and telephone calls, but that I have an outage tomorrow from 8:00 to 4:00 and on Monday from 8:00 to 5:00. So it's kind of inconvenient. You recently had a power – oh wait. Let me just say, the last one I had was Saturday 8:00 to 5:00, and that's just really inconvenient because we're all home so we make plans to have no power. And then what happened is they never even shut it off. So all day long we were waiting – any minute the power is going to go off – and it never went off. And so that's probably one of the things is to make up for that one. But you had one recently, right?
Well yeah, but there's an old thing here. In Southern California they always say we're not without our faults.
I guess because of earthquakes. So that's one of the reasons why they're doing this is because they're putting I guess homes that aren't wooden, that aren't so combustible.
There's apparently two reasons. Our cities' poles were put in probably 50-80 years ago so a lot of them are just tired out and old, termite damaged; then we get the big Santa Anna winds and it can blow them over and it's caused a lot of our great wildfires in the last 10-15 years. So they've been slowly replacing bad poles with up to speed poles.
But then the other good thing is we heard that the reason there are so many of them is because we're going to 5G. And I just wanted to tell everybody out there we're going 5G so we can bring these shows to you really fast. If you believe that you'll believe anything I tell you.
I guess the 5G only extends out like maybe 500 feet or so, so they have to put a lot of those devices. I heard something about that; I'm not an expert though.
Well let's look at my disruption, and I can tell you what happened to be right up close because the view you're going to see shortly is me on my balcony about 20 yards from the chopper.
And this was a Sunday, and just to be clear; he was told not only about the power outage but he was also told to evacuate.
Well actually the helicopter pilot told the guys on the ground to go get ahold of that little white haired guy on that balcony up there, because dammit there could be a problem.
I guess it's called a crash zone; your house was in a possible crash zone.
But I thought this very intriguing seeing a new pole just drop right in there. Isn't that great? Those guys are scurrying around; look at the wind from those rotors; those rotors are whipping that wind around those guys. I'm surprised their hard hats stay on. This is when he's coming down to look at me, and probably a little reprimand.
Here you're about eye-to-eye.
So it gets exciting.
It's crazy how close the helicopter is to you right there, because you're probably not even zoomed in; this is probably just normal.
There's no zooming.
Well I think that it's interesting to think; like this is happening to us quite often and we're in a residential area. But I'm wondering what it would be like to hear a business, or even if you were a dental office. Like I guess maybe some things are battery operated and maybe there's generators, but have you ever lost power with a patient in the chair?
Are you permanently picking on me? Yeah, I'll tell you a quick story. It's a true story. It actually happened in the late '70s and I was practicing. It's December and we all know in December the sun is very low and so about 4:30 it's getting dark isn't it? And I remember walking into the operatory at about 3:30 and I could look out the window and see everything. When I came in at 4:00 I could see my reflection in the mirror and it was getting dark. So I had opened up a tooth, I can cleaned and shaped, I fit cones. And there was a couple flickers, there was like a little bang, and it was black. But remember, it's sundown so it's not black black.
Well this is going to be a problem. In the old days we didn't have all the electronics; I had a Bunsen burner. So on the Bunsen burner the propane was working perfectly. So the patient was a little concerned because they didn't want to come back, and I said not to worry; it's getting dark but with a few candles we'll be able to do the down pack and the back pack. Because we didn't have an obturator back then; we took little pieces of segmental gutta percha, we passed it through the flame, and then it got passed to me and put in the canal, pack, pack, pack, pack. So squirt, pack, squirt, pack; so anyway that's how we did it. So I finished that case completely after dark with just a few candles. I'll always remember, that was a fun experience. And it was a great case.
Yeah, I don't know what people would do nowadays if got a notice that said you can't practice Wednesday because your power is going to be out all day. That just seems like a big inconvenience.
Especially if you cancel all your patients and then they cancel the work.
You know I think – I understand that they are doing upgrades and everything. I guess the most annoying part of it is of all the ones I've gotten 50% have just been canceled. And usually they've been canceled either during the power outage – which doesn't help me at all – or it's canceled and I don't even get a notice that it was canceled. And so I think the communication could be a little bit better if it's not going to happen. They're very good at communicating to you that it will happen, but just not so good at communicating that it's been postponed.
Okay. So let's keep the lights on.
Okay, so now -
Well we had to cancel a shoot.
Oh yeah; actually we did. We had to do it on a different day once because there was a power outage here. Then when we come back everything's a little different; everything has to be reset. I know at my house like all the clocks need to be reset for the irrigation, for the pool filter, for everything.
You know I don't want the audience to worry because I have 5 grandchildren and I have the shooter back behind. But the other 4 are on bicycles and they're spinning circles and they're making electricity and they're sending it right here to the set; so we will have power today because those 4 kids are pumping their legs off.
Okay, let's get started with the show.
SEGMENT 1: Mechanical Glide Path Management
Welcome again. I'm really excited about today's program because I like helping doctors. I fell in love teaching years ago. When I was in college I used to be a T.A., a teacher assistant in math and physics and I always liked it when kids got it; they were my peers, they were my age. And so I got into teaching as an endodontist and I can tell you our topic today I'm pretty excited about because I can help all those young dentists, and even sometimes the old timers get a little bit better at glide path management. So let's get started.
When can you use a mechanical file? That is a clarion cry that I hear around the world. I have the canal catheterized, catheterized I'm at length, known working length; I have a patent canal apically and I have a glide path. So how do I know if I can put a rotary instrument in there and do a little bit of cutting? Well this is how we check the glide path. The stop is about 1.5mm, but for today let's just say it's 1mm. We're going to pull that stop back one stop, then two stops. But here's what I want you to notice. I'm not doing any – I'm not doing any reciprocation on that handle. It's a straight in/out; that's what I'm doing.
So let's get started and look at glide path management. So the question could be how do I know I can use a mechanical file today on this patient in a safe manner? So we pull the file back one stop without reciprocation, slide back. Pull it back two stops, pull it back three stops, pull it back 3, 4, 5 stops. If you can slip, slide and glide you have a smooth, reproducible glide path. We call that in the vernacular a secured canal. So what's a secured canal? It's a canal that has a smooth, reproducible slide path.
You could look at the work and you can see a lot of anatomy here. It probably can be achieved if you have a glide path which can then subsequently be modified and expanded. When it's expanded we have a greater reservoir of reagent; active irrigation moves the irrigant into all these branches, and then you can begin to see during obturation procedures we can fill root canal systems. Pretty exciting.
Well mechanical is really exciting to me because it saves a lot of chair time. If you read this reference right here, this reference has a citation. But in the glide path management procedure itself you can reduce chair time by – listen carefully – a staggering 40% as compared to manual. So if you think about that, that's a big incentive to listen carefully. I think a lot of dentists are getting this, but we were working on glide path management in 2004. This file right here launched 10 years later. You can see the company I work with; they're very nimble, they're very fast; but after 10 years their quickness overcame us and they launched. So now we have this file – and let's talk about this file – and a mechanical glide path.
Well why do you even want a glide path? You want your mechanical file to reproduce the canal; to precisely follow and create an expanded, tapered pathway. All shaping files benefit from that because if your shaping file can go into a bigger diameter canal it has less torque, it's safer, less fractures, less unwinds. So we have a lot of good things – I mentioned the 40% chair time that you saw in the previous citation – and then of course we have my pals; this is the Italian Mafia. We have Cantatori, Castelluci and Berutti – the three Italians, the Mafia we say affectionately. They wrote this article and they showed precisely that chair – post-operative pain chairside is sharply reduced because mechanical files tend to pull and auger debris away from length; whereas our manual files that are stainless steel tend to push things through the foramen and that leads to a lot of our discomfort. We have a choice; we can use rotary or we can use reciprocation.
Okay. Historically mechanical files came to market in the early '90s. Credit John McSpadden, Ben Johnson; they gave us our first two iterations not so long ago. And of course it took us a while to figure it out as teachers but finally we all agreed on an international protocol that we probably shouldn't put a rotary file into the canal until we've at least used a 10 and 15 to length. The problem was – we were getting better, we were thrilled with what we were doing but we knew very little – but we finally were discovering what some of the issues were. Colleagues around the world were not recognizing how absolutely stiff the end of that stainless steel 15 file was. So we had a stiff file; it was not so flexible in the delicate, apical, microanatomy. And then finally these stiff files were oftentimes used in an inward cutting motion, so we saw a lot of what? We saw a lot of what? We saw blocks, we saw ledges, we saw transportations apically, and we saw sometimes perforations. So collectively we can say there was a lot of iatrogenic. So this led to a lot of incentive to like maybe we can just clean that up and get rid of the stainless steel 15 file, and of course that's what we did.
And so then what? We invented Pro Taper. Pro Taper had a pro glider. So the pro glider was a precursor – you can call this a baby pre-shaper. So the baby pre-shaper gives us a tapered pathway much bigger than a 15 file. So think about that. We can get rid of a stiff file and we can use a really flexible file. Because what do we know? This file is Niti but it's got heat treatment, and it goes through M-Wire technology. So M-Wire technology is a pre-machining event. So they take the round wire, the heat it up to proprietary temperatures, they let it cool back down, and when it cools it goes through a phase transition and we get – oh, this is what you're going to want to hear – if you compare a 25/04 Niti with a 25/04 508 Nitinol, that gives M-Wire, and the increased resistance to cyclic fatigue was 400%. Remember in another show; this is a file, goes around a curve, you have compressive stresses, on the outer side you have tensile stresses. So that's how you take a paper clip and break it. So I tell anybody here you can do that you should be thrilled because that's called safety, better patient care, and of course you're having fun. So let's get this off the board and let's continue on.
M-Wire. Well we didn't make a fixed tapered file because a lot of the dedicated glide path management files on the market today – and every company has them – but listen carefully. Every company has series of two and three. You don't want more files. The clarion cry around the world is less is more. So we wanted to build a single file, not two or three, to go in and give us a more predictable pathway for shaping. So this means this file doesn't cut over length because a fixed tapered file tends to have long engagement zones. Whereas if you change the taper like the Eiffel Tower then what you really have is a very selective instrument that just cuts in a little zone.
So anyway, if you notice we'll go forward and you can see this a little bit better. The requirements then would be 300 rpms. You might think in fact that's a high torque. Read the citation; there's many citations, I chose this one for fun. But what I want to say about why the high torque? Because basically your file is cutting in a very small zone. We don't do very much with the front end of the file; it's pretty passive. This is the steering wheel on the Niti car and that's what guides it through curvature and re-curvatures. We pushed the workload up to the bigger, stronger and more efficient blade, so we need more torque to turn that file because we're working with stronger, safer and more efficient blades, okay? So that's how that would work.
Another little comment to make about this file is how does it fit into the international protocol that we taught for so many years? So we said 10 and 15. Well, I’m going to propose you dump the 15 file and replace it with a much more flexible file, more resistant to cyclic fatigue, and it makes a bigger tapered pathway. But if you look carefully you can see that the front end of these files is basically the same; 15, 16, 23, 24. A human hair – the small human hair is 0.06; it's equivalent to a size .06 file. So we're not even .06mm difference; we're really only just about .01. So the front end's the same. But where you really see something – where you really see something is where? Right up in the body. You see that compared to our 15 file we are about 41% bigger at D12.
So I have good news and better news; can you believe it? The good news is one file; the better news is one file is safer and cuts a bigger tapered pathway. I have nothing but good news today; everything is absolutely the best it can be. Oh, I did that just to get your attention.
Okay, so let's go forward. Dump the 15; now you have a 2-file sequence. I've got better news though. We might not even use the 10. When you're a younger dentist with less experience this is in fact what? This is the training wheels on the bicycle. This is a very – around the world we all know the 10 file; we know how to use it. You can catheterize the canal, you can secure the canal, and then this will follow perfectly. We'll see in a little bit that we might not even actually use this file. But right now I want you to think about it as part of the 2-file sequence.
Well you might have thought from 10-16, maybe that's a pretty big jump. Maybe from 10-16 is a pretty big jump. And you might even say you know, 10-16, that sounds like that could be what? That sounds like that could be 60%. No. Just on the table theoretically it's 60%, but not clinically. Why? Well because we know that the 10 file has 0.32 – thirty-two hundredths of a millimeter – over 16mm of blades. So if you divide the 32 by the 16 and we know that you have a 0.02 taper, that means millimeter per millimeter. So if you add 02 to 10 you're at 12. If you use a patency file – I'm screaming; can you hear me – patency! Oh, I love this; patency. If your patency you've transitioned your foramen at least to a 12; so then you could say well really are we going from 12-33%? You could argue that, again theoretically but not clinically. Because clinically what do we know? Clinically what we know is you're moving that instrument. That patency file is going in and out, in and out. And when that file is going in and out until it is loose – did you hear me say super loose? Super loose! Then you know that the canal – the dimensions of the canal are actually bigger than the file that cut its shape. So what we can tell you then is it's more like a very, very modest 23%; and that's actually nothing. That's nothing. So that’s an easy transition for a mechanical file to follow: 10. I hope you're learning a little bit; we're getting a little technical but some of these ideas if you take them chairside you're going to be surprised how easy your canals begin to shape and how you'll have less broken instruments, less ledges, less problems. Okay, I think we can go forward.
Well I mentioned you had a choice earlier and I said you could do a rotary file; so we could have a rotary option right here. You can see it in gold and you can see that we have a reciprocation right in here and that is another way to think. So let's look at these a little bit closer.
You can't see though, these two mechanical files have some differences. Again the gold glider, which usually is used in conjunction with the fastest growing file in the world, shaping system, WaveOne Gold, it's a little bigger hole. So if you look at 8, 12 and 16 this will cut a little bigger tapered pathway than the Pro Glider. They're both really good glide path files and they're single instruments. So this one's going to spin, got a dedicated motor. You probably already have a motor; as long as you can get 300 rpms and about 4-5 Newton cm. of torque you're good. If you're in the market to buy a new motor this X-Smart Plus IQ is not so bad. It has an IQ – like Ruddle – and anyway you can see that this is a spinner so it's going to go full clockwise rotation. And then you can see that if we go down to the reciprocation file it has – we can change the mode on the motor. So if you change the mode on the motor we can go to Pro Glider.
I want to mention these angles. These angles are engaging; if we engage it's 150°. The disengaging angle – disengage – is 30°. Thirty from 150 is 120. After every three cutting cycles the file has made one continuous circle. And as we saw on another segment that we filmed just a couple weeks ago, that serves to pull and auger debris. My friend Mike Scianamblo likes to say it hauls; it hauls debris up into the pulp chamber where it can be liberated. So pretty cool stuff, huh? There it is reciprocating; there it is doing its 150/30, 150/30, 150/30.
So let's take it to a pretty tough molar. It's got re-curvature, got a fercal side concavity. We can see as this thing comes around there's anastomosing between systems like flags flying in the breeze. Well let's go through some basics. First we want to what? Cut a good access. So I think I'll just pause. I'm going to stress access. Let me get that back on.
Notice... What have we done? What have we already done? We've done quite a bit of pre-enlargement. Just like you general dentists don’t put the margins on a crown prep first – you knock down the occlusion, you break the contacts, you reduce the tooth buccolingual; then you land your margins, you're finishing. When we're down in this red zone we're finishing. And it really helps to have pre-enlargement.
And then the other thing I want to stress is you should have everything – that means this pulp chamber is loaded – it's loaded with what? A viscous chelator like RC Prep glide or Pro-Lube. A viscous chelator does three things; it's a lubricant, it helps our file slide when we get into this collagenous vat basically – collagen is how we make glue in industry – it's dangerous material. It's an emulsifier which means when you pierce into vital collagenous tissue when you pull the file out the tissue tends to re-attach to itself and now you don't have a favorable pilot hole to place the file. So a viscous chelator prevents the re-adherence of vital tissue. And finally our file is generating debris and that debris needs to be held up into suspension so it can be later and subsequently flushed out of the tooth. So that's the big three that we get from a viscous key layer; lubrication, emulsification, floatation.
So let's put this file – oh, I wanted to say one more thing. Notice: you've been taught to pre-curve your files in anticipation of the apical one-third anatomy. Well when you don't have pre-enlargement you can stick a pre-curved file in another system; you'll knock the curve off the instrument and the curve – the instrument is now straighter than your intention when it arrives where it needs to be curved. So a pre-enlarged canal can accept the pre-curved file; how about that one? Little, short, watch-winding strokes; a little bit back and forth on the handle; very gentle. Remember the basketball analogy; when you're playing basketball and you put the ball on the floor, if it's inflated the ball will bounce up. This means clinically we never attack, we never push, we never force; we bounce off resistance. So if there's a resistance, pull the file back out; re-butter it. You'll put more viscous chelator on those flutes and that will drag viscous chelator deeper into the canal so you keep getting lubrication, emulsification, floatation.
Now we're in this viscous chelator and where flutes are dragging it down into that collagenous mass where going to get the big three. And I might just stop this just for a second. You know a lot of dentists don't like viscous chelator because why? They say well, I like sodium hypochlorite. That's fine, but how much sodium hypochlorite do you think is in that canal? You know the little kid that has the bucket of water; they go to the shore, they get the bucket of water, they pick it up, they put their fist in it and their fist displaces water. You can have your whole pulp chamber loaded with sodium hypochlorite, but there's almost nothing below the orifice. And then when you put your file in what limited space there is, you're displacing that reagent and you're working almost dry. Viscous key layers will keep you out of trouble.
Now if you don't want to use viscous key layers I'm going to say fine, you're right. But then do use them or consider using them in longer, narrower and more curved or re-curved systems. It will really – you'll notice your endodontics will bump up to another level.
So let's go ahead and finish this. Again you can always put a little more viscous chelator in the pulp chamber if it's getting spent. Remember it's the file that's carrying the viscous chelator deeper. And as you're watch weighing these little, micro – if I'm the file I'm not doing these big, gross movements; it's just a little back and forth, 10, 15 degrees; everything's really soft, light touch. Because you're manually – you're manually reproducing the canal.
Okay. Everybody likes to do this. Everybody likes to do this reciprocation stuff. But when you get about one stop off your reference point, slide. Don't turn a file that's pre-curved back and forth, or in one moment in time it's over here, then it's over here. You're tearing the foramen. You'll have more post-operative problems. Patients will call you more frequently; you'll have wet canals, bloody canals. So it's just a slide; in/out, in/out, and at this time you could use a triangle – an apex locator, an electronic apex locator. You could use a conventional film, okay, digital; darkroom based film technology. But I want you to get your working length. And when you have your working length now you know exactly where you are related to the foramen, the terminus.
And what I'd like you to do now is consider something else. Patency. I don't hear you. Say patency. P-A-T-E-N-C-Y. Okay? Great clinicians know to the patent. And you work that file 10 times, 1 time, 100 times until the file is what? Oh this is my favorite part today! Can you saw loose? When that instrument is loose it's not a 10 file length; it's almost a 15 because a loose 10 is almost a size 15. So work those instruments until they're loose. Some of you – I see you around the world and you have a file at length and when you pull the file back the patient's head jerks because it's a tight 10. So make the distinction. It has a distinction. A loose 10 versus a tight 10.
Okay. So we can go on. I told you this earlier in that first slide, but how do you know today it's appropriate to use a mechanical file on your patient in a safe manner? Pull the stop back a stop; slide back, two stops, three stops, four stops. When you can slip – say it after me: slip – slide and glide, and that instrument passively travels through re-curvature and to length, you not only have a glide path, you own the glide path and mechanical files will follow. Okay.
So you can see we have our viscous key layer; we have a beautiful slide path; all shaping files if you want to go further on the preparation will behave more successfully with less problems. If you're a GentleWave person out there you might be all done; because the emphasis on minimally invasive endodontics – the ProGlide you notice is about 85 hundredths at its most shank side flute, and it's about a 16 at length, and if you work it a couple times you probably have an 18 or 19 at length. So for a lot of GentleWave users that is a good prep. They don't need to shape a lot because they can put on their staging platform and they can get their reagents in here and they can clean a root canal system. I don't know how the hell they're going to fill it, but right now we can clean a small shape; it's possible.
Okay. I'm going to show you something now that I would say we're ready to take the next proverbial step forward in training. Not all of you, but I want all of you to hear this; because you could all do this. I've taught this for decades around the world. You know what I'm most proud of? The things we teach, they're transmittable; they're reproducible; others can do it. If I'm the only guy that can do it or Herb Shilder is the only guy that can do it, or John West or Professor Marchou or Tom McClammy, it's probably not a very good technique. It might be good in our own little four walls, but we've got to teach things that the whole world can embrace and really enjoy the success.
So what I want to say about this is most of you love to peck and push, and try to jam instruments – I hate to say it – towards length, even when you notice what? I hope you can all see, there's quite a bit of curvature on that root, and this one over here, that one, this one is also fairly curved. So I want to have you hold the handpiece different. Most of you are way up here, you have your index finger pretty much up on the head, and you're being a pecker, huh? Don't be a pecker. Float; say float. Follow; say follow. Float, follow, run; say run. Let the instrument run.
So let's show you wrong; let's look at wrong first. Oh, okay. So let's look at another way to hold the handpiece. Let's look at a different idea. Now remember; nuances are the distinction that make the difference. A lot of times in life it's just a little thing that’s preventing you from being more successful and taking that next proverbial step towards success. So let's let the handpiece – here's our webbing between our thumb and our index finger – let's just rest the handpiece in the webbing. And because it's a progressively taper file it's now going to screw; it's going to run. Let's watch; let's quit talking about it; this is exciting stuff!
Notice I'm way back here. I even took my index finger and my thumb off to show you how that walks around the curve. And notice it's arriving right now. That's about a 60° curve. No 10 file, okay? So if you learn to hold the handpiece right and float/follow/run, then if the file keeps advancing stay the course. If the file bogs down take the file out, put in some more irrigant, clean the blades – because your file is loaded with debris – that'll give you active flutes to engage. Put the same file back in and oftentimes it will run to length. I would say with no 10 file, in my experience about 75%, let's go public with that, about 75% of the time it's completely a mechanical procedure. Guess what? What if the file only gets down to say part way; you take it out, you clean the flutes, you re-irrigate, and it comes back down and you know what; it just can't go deeper. Guess what? Take your irrigating syringe, pull back, vacuum out all of your reagent, top off with a viscous key layer, grab your 10 file and do what you would have done anyway. Okay? And you'll find out maybe 20-25% of the time you have to grab a 10 or an 8, or even an 06 sometimes, to catheterize the canal, to get your working length, to have patency, and then to verify the glide path.
Okay. So let's do those things and you're going to notice it'll be a whole different kind of world.
So in closing I'll try to bring it home. Two slides. We said that there is mechanical glide path. I would think in any procedural protocol you're using a mechanical glide path. The only question is are you using a manual file first to secure the canal; or are you going in with only a mechanical file? Those are things you can work on. And don't take chances; remember, make yourself the patient and you'll have the answer. You'll never have to take a chance because if you were the patient you'd say no, no; don't do that.
So notice it hasn't been catheterized. We still have collagen in these canals, we just have a great access. We have sodium hypochlorite in the pulp chamber; here we go. So we'll reciprocate over here, 150/30, 150/30, peck, peck, peck, peck. And over here it's a smoother action because we're spinning and we're running. Oh, it's a marvelous feeling; you see the rubber stop closing in on the preferred reference point and you know you're going down to all’apice, ci vediamo all’apice. So you're almost at length, and now we are at length and now we've got the file out and you have the best glide path you've ever carved. So you can do it with a lot of different files; it doesn't even have to be these two.
So in closing I'd like to leave you with one thought. Whoever owns the glide path wins the shaping game; actually the inner game. Because if you have a great access and you've identified all of the orifices on the pulpal floor, and if you have a glide path – everybody can shape; everybody's shaping file pretty much works; we can all irrigate and use active irrigation; we can fill root canal systems with warm gutta percha, and we can win the game.
See you next time.
SEGMENT 2: Local Dental Representatives
Okay, so today we're going to talk about dental reps and how you can maximize your interaction with them. Working in the front office I see various reps pop in periodically and say hi, and they want to know if we need anything. Some are very professional and seem to actually know you and the rest of the staff. And then there's others who are a lot less professional, seem a little bit lost and can't even pronounce your name. So obviously not all dental reps are created equal. Is that true; is that safe to say?
That's very accurate.
So what are the different kinds? Like I know I've heard you talk about two different kinds. Why don't you explain that?
Well you know we have a bunch of reps in dentistry, and probably I'm just going to talk about endodontics because we're an endodontic practice, but this would probably be pretty much true for GPs. We have generic reps. And a generic rep – I don't want to say anything disparaging to Henry Schein's people, but Henry Schein sells a wide array of products. I mean catalogs like – it's like a phone book. So when that rep comes in, a generic rep knows a little bit about everything but doesn't know very much in depth about anything. So they're helpful people and if you drill down a little bit and you start getting into endo or sealant or something, if they don't know they can probably find out. But they're not going to just be able to rattle it off their head, usually speaking. I'm sure there's exceptions to the generic rep.
The other kind of a rep is a specialist rep, and they're called Endodontic Specialty Reps and they're - I'll just speak about the company I've worked with in dental products throughout the years, Dentsply Sirona. So in Dentsply Sirona's world – I don’t know if you want me to go into the boot camp and all that right now – but they're really pretty heavily trained. And when they come out of their boot camp they have done a lot of procedures; they actually do root canals, first on plastic blocks and then they'll harvest at schools extracting teeth. And many, many reps are doing root canals in their proverbial basements at night, so when they go out they have some experience. When you say it's rough, it's clicking, it's pulling me in, they know what you mean.
Okay, so obviously some reps you're saying know a lot more in depth about their little area of focus.
Because it's just endo.
So they can obviously tell – all reps probably can tell you about some products and give you information about them to a certain extent. But what else can they do?
Well the reps are really good at what's trending. So an example: if there's something new in diagnostics or you name it, there's a lot of competition in the endodontic field so if the rep either has the new technology that he's familiar with or that she's familiar with they're going to be real excited about it. But they'll also tell you what the competitor is selling and what's new, and they'll be able to tell you quite a bit of information.
So they're very good at trending, they're very good at knowing what's going on in your community. Like say there's 100 dentists in a city. They'll pretty much tell you 70% are using this file, 20% are using this file and 10% are using stainless steel. So they know a lot about what's going on because they have their fingers on the pulse.
And so they probably also know a lot about maybe common problems that other clinicians are having as well?
Yes, because one of the things that Dentsply Sirona has done historically which I think is good; each rep is mandated through documentation to make 8-10, maybe sometimes 8-12 office visits where you don't just phone or email; you knock on the door and you go in. So they're out there and by talking to people they're learning too and they're finding out – like if a rep comes into our office they probably wouldn't talk to me unless there's an appointment. But they have a relationship with you, and so you guys will start talking as an example. This isn't even true what I'm saying, it's just psycho-drama role playing.
But if you did have that – you have kids, I got kids; you go to that church, I go to that church; you play ball, I play ball; you like to go to Hawaii. All of a sudden the more of these connections you can make, as in life as it is in business, it's about relationships. So if you guys get into a relationship there's some trust that forms and all of a sudden that's kind of like one of your confidants. Like we have a doctor, we have a dentist, we probably have – some women have a hair stylist, some people do their nails. I mean we go out to have things done; well they know what's going on in dentistry.
I guess if they're kind of aware of some problems that other clinicians are having and how they solved them they might be able to give you some tips to help you solve your problem. But how – I know that we've had actually dental reps put you in contact with a doctor for help, so they can help you find help too if they can't help you themselves.
Why don't you tell me about how you like that done; like the protocol for a dental rep trying to get you to help another clinician? How would you like that done?
Maybe I ought to look at my camera. Okay, what I don't like is Rep A goes to a dentist and the dentist says you know I'm breaking quite a few instruments. Okay, I'm going to help you solve that because we've been through glide path, patency, and you're still breaking instruments. You tell me you're not pushing, you're not pecking, you're floating. So maybe we could have Dr. Ruddle or Dr. X anywhere; would you be willing to have them give you some coaching? What I don't like is to call up the doctor and say gee, I understand you're breaking a hell of a lot of instruments over there so here I am. I'm Cliff Ruddle; I'm here to help; I’m on my white horse!
So anyway what I prefer is tell the rep I'm happy to speak with them because that's my protocol. Tell them to give me a call, email; let's set up some mutually agreeable phone time, and then I know they want help. So it's nice to know you're wanted help by the customer versus you're going around cold turkey calling somebody that might be embarrassed frankly.
Yeah. I guess that would be – and probably you don't want them to just give out your number either without talking to you first.
I'd prefer them to set it up. So good reps know to do that if they know Cliff Ruddle, and I've worked with reps for 40 years. But I take lots of calls that have been set up through reps where I'm talking doctor to doctor. But the only thing, to your point, is the doctor calls me.
Okay. You talked a little bit about Dentsply Reps and how they go to boot camp. What is that exactly?
When you are hired by Dentsply Sirona to be an endodontic specialist – which you're not; you know nothing probably because you came from other industry – they actually go to Tulsa, Oklahoma and they go through a 2-week boot camp process. And there's examinations, there's practicals, plastic teeth, extracted teeth, they take x-rays, they have to know chemistry of sealers. So it's like a little mini school, a little crash course, and then of course a lot of them shadow. So when they finish boot camp, and say you're another rep that you've been for 5 or 10 years, you have a lot of experience, you have clients, you have relationships like crazy; a lot of times I work with you. I just shadow you. I go with you; I'm like your shadow so I go with you wherever you go and I watch how you interact with people, your sense of humor, how you get in there and make people comfortable. And that's really all it's about is getting into a relationship. It's hard to get into a relationship if there's not trust. So which comes first?
So they really have a lot of training. And I think you said something too, that they'll even sit in with you with the patient?
Do you request that?
It's very normal, in the United States anyway, for the rep to see that there might be some challenge that isn't amenable in a quick call. Because when doctors are practicing, rarely do we want to get up, leave the patient and go talk to the rep. I mean sometimes we'll do it if it's slow and I'm between patients, and just because they're a friend. I look at reps as an extension of my practice. They're an extension of my success. It's not us against them, commercial, non-commercial. I mean – where's your phone?
Well you bought a phone, okay. So everybody gets upset because reps are selling something. Well somebody was selling you an Apple. Somebody sells me on maybe I should get a new jacket because I looked pretty crazy on the set wearing three coats for the first season. So we're all buying and selling. I'm always trying to sell you when you were younger on college. You're trying to sell your kids on work hard in school. So dentists are selling their services to patients. We all sell and we all buy. So to me I don't see them as sales people; I think we should start looking at them like confidants, friends, give us trends, tell us about problems, and tell us what's going on right under my nose in my own community. Because a lot of times when you're working all day long you don't know what's going on here, here, or just behind you. Well they'll say Harry; he loves this whatever and he's one of our best customers; he's been using it for five years and you might really benefit. I know Harry's my friend, we golf all the time; I didn't know he had that product. So they're really good at helping you keep current.
I think you also said something too; that a well-trained rep, like a Dentsply Sirona rep, can even help you with financial planning. Is that correct?
Oh this is really cool. One thing that the Dentsply Sirona reps can do almost every time is if they know how many cases you see a week, if they know what kind of teeth you're practicing on, if they know what your fee schedule is and how much time you're spending on each case, if they know what your mortgage payment is – your most expensive thing is your staff, your mortgage and your supplies – they can put together a business plan and then we can design success intentionally.
So I've seen them go out, I've heard many dentists tell me how they're more profitable, they're more cost effective, they're more efficient; because they're scheduling better, not so many appointments, and the reps can really help you in the business of endodontics.
So they're very informed on trends, they know what's out there, they know their product, and they can even help you problem solve.
They know their competition too.
Yeah, and they can help problem solve. Is there anything else that they do that you can think of? I mean I guess there's specialty reps that go into dental schools too.
We do have – Dentsply Sirona does have specialty reps that just do the universities and just the post-grad residents, which means what? You can't even get into a school – most competing companies with Dentsply Sirona – they can't get into the school. Because the rep is too commercial. These reps actually sit in seminars. But it starts with the rep has a relationship with the department chairperson. And that chairperson then says you add value for my residents; you can come in. Now they're not the only reps allowed; there's other companies. But a lot of companies when I'm at dental schools teaching residents, they're just not allowed. They don't want them in there, they're too commercial, it's just about selling.
I guess it's nice that they get to see what the young people are thinking; like how they're thinking, how they're looking at things. Also I guess a rep can maybe direct you to course work? I mean everybody needs that, right?
I guess we're making quite a laundry list. If we were to put them all up in bullets we would have thought we should have more reps in our lives. But yeah, they can steer you to study clubs; they can find out some big named speaker that's coming into their community and they can tap you on the shoulder and say let's go there together. You know reps – to me again when I go to Europe it's so different. The reps are part of the alliance; they're part of the professional team; they're welcomed into the teaching areas, the schools and stuff. I've seen it more stand-offish in the States; I think that's the big deal about commercialism. But I think we should get over our pride and we'll be better dentists practicing and serving our patients if we're wired into what's happening and trending in our communities. Because sometimes dentists are four-wallers; and a four-waller just – they go in and they've got their four walls. I guess they've got six walls if they have a floor and a ceiling. Anyway, they're in their environment and a lot of times you're busy; the days go quickly and you go home and you're tired and then you do it all over again; and they do that for like the next 30 years.
So if you get outside of your environment – like when Jessie was talking to us about stress management in a recent show – sometimes just changing the context changes the outcome.
Yeah, it's nice that – it seems like if you are a four-waller then maybe your rep is sort of your connection to the outside world.
That's your lifeline.
What about that job? Do you think that's a good job? Like if someone, some young person want to get a fairly well paying job, maybe get out – not behind a desk but they're out visiting other offices; do you think that would be a good job to recommend to someone?
You know in Europe Lisette, most reps are dentists. So I'm saying that to kind of is it a good job. A lot of dentists go through dental school, and they like dentistry but maybe they don't like the demands of the practice; or maybe they're not good with people, but then they might not be good reps. But anyway for whatever reason, Phyllis and I have run into so many reps that are actually doctors; and so that is very normal.
And they do have – like they get a cell phone, right; they get a car? Is that correct?
A lot of them do; laptops.
There you go.
And then -
They get a per diem. They get a lot of benefits. The one thing that's kind of changed is the reps used to like to take you to dinner. They'd drop by your office, but let's just say they come by a few times, then you finally arrange to meet them, then all of a sudden they some little thing to you, or they say have you ever thought about trying this, or have you considered this? And all of a sudden you try that; well if it adds meaning to your life and it's making your day better and you're better serving your patients, you get excited. So then you might say well maybe we should have a dinner; the rep might say that. Well that's great. But usually that's a little bit more infrequent, and then lunches of course were common; but what happened was the Sunshine Act. And the Sunshine Act came into medicine because you know pharmaceuticals sent MDs off to islands and said here's a junket to go golf for a week and here's your free golf clubs, and here's your watch and all that stuff; and then please go back to your office and then write a lot of prescriptions for Viagra. Write a lot of prescriptions for whatever.
So the general public and the Congress of the United States got aware of this and so they enacted the Sunshine Act, and so now lunches are more like a Coke and a hamburger, and a dinner might be French fries.
Or maybe they're just inviting you over to their own home for dinner.
If I were a dentist I'd take my rep out to dinner; how about that one you guys out there? Don't be cheapskates.
Well it sounds like a rep can offer you a lot. And probably – I'm thinking that maybe a lot of clinicians aren't just maximizing their reps. They can do a lot for you and they can be confidant, problem solve, a lot of things.
Who would you say is the best rep you've ever met?
So if I give this name out, those other reps – because there's 150-some Dentsply Sirona reps that I've held a lot of their kids in my arms; I've gone to dinners with them for decades. So now if I give a name the rest of them are going to be okay with that. But I will say -
They're all good, but who is just way above?
If I was putting together a team and I was a company there would only be one phone call and it would be to Victor Onwudiwe, and he's in Canada. And Phyllis will tell you Victor, when he was first a regional rep for the Toronto area, the greater Toronto area, he was always in the top 1, 2 or 3 in all of North America in terms of sales. Now think about New York City, Manhattan, LA, Chicago, Miami. And you know Toronto is a big city, but you get outside of Toronto and there's moose and there's elk and fish. I mean there's a lot of dentists, but that guy has such incredible respect at the University of Toronto. Shimon Friedman and Anil Kishen and all these people, they love him because he makes their school more successful. And they hold classes there and Victor goes around with his reps underneath him and they knock on doors and say go in there; Pierre Machou, Professor Machou is going to be giving a class. He'll be there in two weeks. So they help fill those university programs up. And they do hands on classes.
Well Victor was so good that he got a promotion and he's now running Dentsply Sirona Canada, more or less, and I would call him.
He's Nigerian, right? Is that correct; he's from Nigeria?
Oh, he's the Nigerian Express. Oh yeah. You're going to want to meet people like Victor in your life because they just make you feel better about yourself.
Well that sounds nice. I think that – do you have any closing comments? I think that we've given a lot of information that might be helpful to some clinicians.
I do have a closing comment. Model success; success leaves clues.
Okay, that's the end of our segment for today.
We're going to close our show for today with demotivators. We've done this before last season, and this is our demotivator box. And they motivate you, they're cards that motivate you through reverse psychology. So the one that I pulled out is disservice. And I'm going to read it and then my dad's going to comment on it.
It takes months to find a customer but only seconds to lose one. The good news is that we should run out of them in no time.
Here, let me give you this and you can comment.
Oh. People don't care how much you know until they know how much you care. So what that means to me is you can do a lot of training and you can take classes and you can get all the new technology in the world; but if you are an arrogant person and you can't communicate well, and you're just kind of gruff and it's about you then you're kind of probably practicing on extracted teeth.
Another thing I hear a lot around the country, and endodontists call me a lot; they'll say as an example Lisa – oh yes, what they say is you know, I'm not very busy. And you talk to them a little bit, but then you talk to four or five more endodontists in their exact community, like during lunch at a convention, and they had to hire two associates, and another guy had to pick up an extra day a week. So why in the same dynamics, the same socio-economic geographical region, can we find slowness and incredible success stories in business? And I think it has a lot to do with my opening line; they don't care how much you know until they know how much you care. And if people know you care they think they're in the right place.
Okay. It also kind of makes me think of the dental reps we were just talking about. There are just so many like files for example available; how can you find a customer that wants your file – to buy the file you're selling? It seems like it could be hard to find that customer. And then maybe once you do maybe you make one little mistake and that customer just leaves you. I mean I think people are less likely to join you when they're already used to what they're doing. So once you do get them to join you then you need to really be of service to keep them. Because people will just – there's just so much competition; they can go find something better somewhere else if you don't give them the service they want.
I guess I'd make one more comment. We all have walked into a medical office – a dental office, a barber shop, whatever – and sometimes when you walk into these environments it's like gosh, there's a lot of energy. And you can just feel it, and you don't even know what's happening but you want to be part of it because it feels good. But you walk into some places – and we should psycho-drama role-play – but I can walk in to the front desk and you're just – ahem. Yes? I mean when people come in they've got to be like that's your customer. Like take care of them; treat them like a prince.
I know. I actually – sometimes I go get coffee every day and I'm sometimes just standing there. And I say to Isaac, are we invisible? Because no-one's coming to help us.
I shouldn't say this, but I went to my dentist recently – his name remains anonymous but it's a phenomenal dentist – to have a restored implant. And he had a new environment and some new people, and when I walked in I thought I was in a mortuary. And finally I said to the receptionist; I said is this a mortuary or a dental office? And she said well; it's a dental office. And I said: "Fooled me!" So you know, I try to make people laugh and I think that's a little trait we should all work on because life – it's pretty serious when you get sick and you lose people and they die. But most things in life you're going to be okay. The sun will rise up in the East tomorrow and another opportunity to win. So let's go get those customers.
Yeah. Okay, let's do another one.
This one is called flattery. And you can maybe tell from the picture what it represents. It says if you want to get to the top, prepare to kiss a lot of the bottoms.
What's that one telling you?
The customer is always right. The customer is always right. It doesn't matter what they say, you go absolutely, yes ma'am. No, I mean in life there's a lot of indignities. We all remember dental school; we remember starting our practice; we remember starting a running program and you're bent over after like a quarter of a mile and you might be vomiting. I mean there's a lot of indignities to work hard. So I would just say keep working, keep working, keep a great attitude.
I liked it yesterday when we were talking about this a little bit. You said something about sometimes it's good to keep your mouth shut.
Right, because maybe the customer – you say the customer is always right. Well in reality they're probably not. But it's just important to not point out to them that they're wrong.
So you know in another psycho-drama role playing, sometimes keeping your mouth shut to your point is you could say something quite confrontationally as a patient. Like do you always run this late? Are you normally behind and all this stuff? And what you do is just listen. You don't argue, and certainly don't defend yourself. Because we all want to be right so it's really important to defend our turf. And I think sometimes as I've gotten older it's like it's okay, it's okay. Just keep listening. In fact just say is there anything else?
There's a lot to say for listening. When in doubt just listen.
Yeah, be a powerful listener.
Okay, so that's our show for today. And did we just lose power?
Are you kidding me? I mean these SCE people; they're taking poles out all the time unannounced and now the show is in doubt.
Was there an outage schedule for today?
Well of course not. This is SCE with a sense of humor.
Well fortunately we've finished.
Where's the candles?
That's our show for today. See you next time on the Ruddle Show.
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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.