Success in 2025

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…Well, what about when that technology is AI?

AI is coming like a train. And I can hear, if I put my hand on the tracks, I can feel the vibrations. If I put my ear on the track, it's coming!...

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

How are you doing today?

Pretty good. How about you?

Excellent.

Okay. Well, this is our first Ruddle Show of the new year. So, here we are in the present. Last year is now behind us, and the future is just ahead. So, two expressions you like to say related to this idea of past, present, future, and I actually find these expressions quite meaningful. The first one is everything old is new again, and the second one is create a future that is not about the past, but that takes the past into account. So, maybe just tell our viewers briefly what these expressions mean to you.

Well, you're in 2025 and you're starting the journey and things will start to pop up. That's life. Pretty regularly. And it might remind you of de ja vu all over again. You've seen this before, haven't you? So, as things pop up, you need to be resourceful and realize that somehow you got to the present. So, you know you're—you're looking at the past, it's influencing how you see yourself and what you're doing, but you don't have to be like that. Just remember everything, there's an old expression, who you are is where you are when, so we're all a product and a combination of these memories and experiences.

But I think you can look at the good things that happen and carry those forward. I like to create a future that's not about the past, takes the past into account. I like that because it's a chance to look at upsets that have actually happened and then to like the hand—break down, breakthrough, take the upsets and get better. This wasn't an upset, but here's a single example in the life of dentistry.

Dentistry and endodontics had reciprocation. So, we shaped canals and there was reciprocation from the 40s, the 50s, the 60s and they were always 90-90, 60-60, 30-30, equal bidirectional angles. Machtou wanted to make the present better than the past, so he took the past into account, reciprocation was the idea, but he chose to have dis-equal bidirectional angles. So, the cutting angle would be greater always than the disengaging angle.

So, that's an example where you can take something that we all use in everyday life, could be endodontics, could be dentistry in general, and we can think of something that could improve on what's already there.

All right, well, thank you for that wisdom. Now, we're just gonna build on that because we came across another expression, past, present, future expression, and that was in an article we found in Dentistry Today News and it was by Dr. Maggie Augustyn and the article is called, “Let Go, Here's to the You Who's Waiting Ahead.”

And so, the quote at the beginning of that article is by Friedrich Nietzsche, and I really like it. It's the future influences the present, just as much as the past. And interestingly, at the beginning of this article, the author gives us the imagery to help explain this expression of a person standing on a ruler. Okay. So, I'm gonna give you a ruler and you can explain to us how this works.

All right, so you're standing on this ruler. Each of you would stand in a different position based on your age, but that would be the present. Then if you looked over here, this would be your past, and if you looked over on this side of the ruler, that would be to the future. So, how you feel in the present depends on whether you're looking past, future. Okay?

So, to look at the future, we have to understand what we're focusing—or to look to the past, we have to look at what we're focusing on. That's going to be important. And then, what we're going to do is ask ourselves in the past, we had different things that might have happened and they were discouraging, maybe they caused upsets. And then, you also look at the things that you solved. You are a problem solver. So, as these challenges from the past came in, you were able to figure out what happened, put a structure in place, turn the breakdown into a breakthrough. And that's pretty much how you're gonna view the future or the present right now where you're standing.

How would you like to view the future?

Okay. So, a lot of people have a lot of fear and anxiety about the future. So, the author asks us to imagine yourself in five years having all the success you ever dreamed of, then how would you act differently in the present if you knew you were gonna be successful in five years? So, maybe you would have less fear and anxiety. Maybe you would have more time for people. Maybe you would just have more daily gratitude and relax a little more.

So, the idea is that you can choose which perspective you want to have. You can actually choose to live in the present with a lot of fear and anxiety about the future, or you can choose to live in the present as your successful future self. And then, with the fear and anxiety removed, the idea is that all these new possibilities will emerge.

Very good.

So, that just sounds very nice and simple, but if you are living in fear and anxiety right now about the future, how can you just flip a switch and change your thinking? It seems hard to just like change your thinking like that.

Well, probably it is gonna be hard, because we're creatures of habit and we do things repetitively, typically over and over. We get in our comfort zone and all of a sudden something new comes up, a different opinion. So, probably I can best tell you how you might manage your brain and start working on controlling it because it is a choice, as Lisette said. And it would remind me of North America, our past history. We had indigenous Indians. One single tribe was called the Cherokees. So, I want to talk about a grand old Cherokee warrior with wisdom.

So, he's talking to his grandson and he's reminding his grandson that inside each one of us lives two wolves, two of them. And one is a good wolf and the wolf is pretty kind, it's strong, it's fast, it's proud. It really represents love and all the goodness in life. The evil wolf is ego, it's ferocious, anger, prone to anger, does really wild things. And so, finally the grandson says to the grandfather, grandfather, which one wins? And the old warrior said, the one you feed.

Okay. So, we probably all need to feed the good wolf a little bit more. Okay. Well, we have a great show for you today, so let's get going on it.

Okay. So, dentistry has greatly rebounded in recent years after suffering a setback in 2020 with the COVID-19 pandemic. However, two persistent challenges still remain, namely low insurance reimbursement rates and the demand for higher wages because of staffing shortages. So, that said, though, there are a number of practices that are experiencing a lot of growth. And you might be wondering, though, why some practices are growing while yours seems to have maybe hit a plateau or might even be struggling.

So, the good news is in their 2024 State of Dental Report, Sunbit identified five growth factors that successful businesses have incorporated. So, we're going to talk about those in a second, but maybe first you explain what Sunbit is because I actually had to look it up. I didn't know.

Very good. It's a financial technology company. And so, what that means is it's a place where you can get money, and I might say a little bit easier with less constraints. As an example—

For patients to get financing?

For patients that are in your care and they're a little short on cash. So, anyway, one thing that they do is they offer you a chance to fill out a form. They say it takes 30 seconds and within just a few minutes you're either approved or denied. And just so you'll know, 90% of all patients who apply for it are approved.

So, that's convenient because that's a big roadblock to treatment for some patients. The other thing they do is the Sunbit, when you do take out monies or loans from this company, it's soft credit, so it's not really going against your Bank America card, your MasterCard, or other banking metrics at lending institutions, things like that, so patients like that.

And then finally, it's pretty flexible and patients can sign up for a more custom terms, terms, you know, length and interest rates and stuff like that. So, it's flexible for patients.

Okay. So, obviously that's a little disclosure because it makes sense that one of the top things on Sunbit's list is to offer patient financing, have it readily available for all patients. So, let's actually bring up our list now. Okay. So, offering patient financing can be a game-changer, right?

Well, absolutely, because one of the major restraints of a patient going through a treatment would be money. And, you know, one of the things that's kind of—well, I don't know if it's surprising to you out there. It was a little surprising to me. Two-thirds of all patients can’t handle a $400 emergency. If something came up right now, they would not be able to come up with the $400.

So, that goes to show that a lot of your dental procedures and the fees you charge for those procedures are going to be well in excess of $400. So, you know, patients are kind of on the edge. We're talking about why they might want financing. They like options. Patients like to have flexibility and they don't want to be stressed out. So, if you can offer financing to these patients, you're going to remove a lot of that anxiety and the fear and they can see themselves following through with what you're recommending.

And finally, my own experience is, we didn't have Sunbit back in the day, but we definitely had CareCredit. And CareCredit is still alive today. Sunbit's just another example. But these are big financial technology firms that offer our patients to pay for things when they otherwise couldn't afford it.

Okay. Well, what about using your dental insurance? Because everyone has that, right? Well, I say that kind of sarcastically because a lot of people don't have dental insurance. And even if you do have dental insurance, you might have trouble finding a dentist who accepts your insurance. So, that leads us now to the next thing on the list. And it turns out that if you want to see your practice grow, you might want to consider accepting more insurance because that will reach a broader patient base. But a lot of dentists shy away from accepting insurance, right?

Well, do we shy away from insurance? I guess, what I would say first of all, insurance companies notoriously don't compensate appropriately for the fees the doctors charge. So, you usually get a very low compensation and that's pretty much the norm.

I said, right at the beginning that the two, one of the two challenges that have continued are low insurance reimbursement rates. So that could be like a detractor.

Well, that's a detractor for your doctor, because if I'm gonna take your insurance plan and work for free, that's a negative. So, you ask for the negatives, one would be the fee schedule is not appropriate with the fees that are actually charged. And the other one is, most offices I noticed, even back when I was practicing, before all this paperless and all the computer stuff, it took almost a full-time person. And then, I Googled it, it takes about 40% somebody on a one-man, one-woman office to run insurance in this day and age.

So, you fill out a lot of forms and paperwork for these patients. Then, when there's disagreements between the doctor and the insurance company, you're paying somebody to represent you to try to ameliorate the problem or maybe get another angle of an xray or some written comment that will throw the switch. So anyway, a lot of staff manpower goes to managing and helping patients with their insurance.

But there are benefits, and the benefits are patients can get treatment timely. They don't have to worry so much about it because they know it's taken care of or they think it's taken care of. If people are happy, they're going to hang around. So, your retention rates of your population of patients should start to grow. And remember, people talk about you in the marketplace. So, if they're going through treatment, it's going well, that's gonna mean more retention and growth. And then finally, they like payment options that are flexible.

All right. Well, we're not ordering all practices to start accepting insurance, because we do understand that there is some amount of hassle involved with that, but high growth practices do tend to accept more insurance, so it's just something to keep in mind. And obviously you need to make the choice that's best for your dental practice, and the choice you make might even be different depending on if you're a general practitioner or an endodontist, correct?

Yeah, I thought about that quite a bit because that was the question she posed to me and I would say yes and no. It just depends on the maturity of the practitioner. When you're younger, you're all things to all people at all times. So, you want them to have insurance and you'll tend to stretch things out. There might be co-payments. And then, we're thinking of Sunbit or Care Credit again. They might make that co-payment. So, insurance doesn't pay so well, but with the co-payment, you'll reach the fee that was charged. So, that's just something to think about.

If you're a more seasoned practitioner and you're more successful and you've built out your office, you have your technology around you, of course that's changing, but a lot of people I know, in fact on the AAE discussion forum, there's a kind of a migration to get away from insurance because—I'll give an example. Health Maintenance Organizations, they're called in the United States, we call them HMOs, they compensate—and incidentally, 88% of all patients in North America have dental insurance. So, the key is HMOs give you 30%, 40%, or 50% of your fee. So, that's a really, you know, the old analogy, you produce $1,000 in a year at a time, could argue a little bit, 70% would go to the big three, salaries, supplies, rent or mortgage, other things. 30% goes to you and you haven't even paid taxes. If you take a 30% discount, you're working for free. So, if it's 40% or 50%, you're paying the patient to have treatment.

So, I think a lot of it just depends on where you are in your practice career and a more mature practice is working more on fee-for-service.

All right. Well, let's now move on to technology. That's number three on our list, adopt technology. And practices that are experiencing high growth tend to be more open to adopting new technology. And so, obviously there's costs to consider when you do that. There's a learning curve to become proficient in the technology. And then, also you need to be able to incorporate that technology into your existing workflow. So, there's challenges there. But what are the reasons that clinicians are investing in new technology?

According to Sunbit, from a doctor's perspective, they want to do better work, they want better outcomes, they want longer prognoses. So, that's what's driving, according to Sunbit, a lot of the technology growth. Also, you want your patients to be excited. You want your patients to go out and talk again in the marketplace, like I just mentioned. So, if you're using old-fashioned technology, it might even start to sabotage your practice. So, patients are happier.

And then, finally, save time. What if you get a new technology that you can shave 10-15 minutes off each procedure? That's efficiency. That starts to play with the scales of economy in terms of your income streams and your profitability. And it's funny, but technology, to get more revenue, that wasn't the first, the second, or even the third one. The fourth thing doctors gave for getting new technology was, well, I'll make a little bit more money maybe. So, it was the other three things, but the one I liked the most was fun. You know, if you're doing something new, you're being challenged, you're using your mind, things open up, you discover things about yourself, and you know, you start to have more fun. When you're having fun, it's not work.

Well, what about when that technology is AI?

Well, when it's AI, we're kind of miserable. As a profession, what was the number? 8%, only 8% of dentists, at least in Sunbit's market, I would think the United States, are using some kind of AI, but yet AI is coming like a train. And I can hear, if I put my hand on the tracks, I can feel the vibrations. If I put my ear on the track, it's coming, like they say, like a train. AI. We've talked about AI many times on the Ruddles show. We've talked about how it can be used as an example for a diagnosis.

So, we found out and discovered on an earlier show that actually it was more accurate than a lot of times general dentists looking at well-angulated films. So, you could use it as an example as a second opinion. So, dentists are doing that. I forget all the little companies are doing that, but that would be on diagnostics. So, AI can predict outcomes.

We talked about the Harvard study, and they looked at where you went to school, what kind of a job you got, what was your income, what was your ethnicity, and what was your gender. And they found that those along with your medical history could start to prognosticate outcomes. So, as dentists do more and more implants, and remember we said in a previous show that there are (178 million) patients out there that have at least one missing tooth, then we might want to prognosticate would the implant be appropriate? So, that's good.

We didn't—there's practice management, there's administrative tasks, AI can do all this. A lot of dentists, at least in the Sunbit, there are better practices, they're using these things for administration and for business. And then, marketing would be the last one. And you can use AI for enhanced marketing.

And we're actually going to talk about that in a later show this season. I think that one of the problems with dentists being slow to incorporate AI into their dental practices is because they might really like the idea of AI, but they just don't understand, like, how to incorporate it. And we talked about, you just mentioned diagnosis, predicting outcomes, practice management, even for your marketing.

So, we're trying to actually bring awareness to the dentists out there that these are ways you can use AI because when we first talked about AI in dentistry, I'm like, but how would that even work? Like, I mean, you don't even know how to incorporate it or you might have it already in some form, but you're not even really clear on what you're doing. Like, I mean, there's some kind of, well, I don't know if it's really AI, but even just having the system that calls patients to remind them of visits and stuff. Well, take that to another level, and then you have maybe AI.

And another idea with AI is you might not know you're using it.

Right.

I've been talking about Innerview and I've had guests on Dr. Cherilyn Sheets but what if you had a little cordless instrument that could tap on your tooth five times, the data goes up to the cloud. Now, you're using AI and you're not even thinking about it and it's telling you the oscillation of the tooth, its recovery time, it's back to zero. It can send you an energy return graph and it can get you more aware of early implant failures, broken crowns that have lost their looting, actually broken preparations or fractured roots. So, you're using AI and you're not thinking, you're just thinking, picking this thing up, and it's just, it's a hero for me.

Okay. Well, let's now go to the last thing on our list of growth factors, and that is that practices that are growing and seem to be successful, they're working at least four days a week. So, maybe you can comment on this from your own experience.

Well, it's pretty obvious the more you're available, the more likely a patient is to stagger into your operation. By accident, you're staying busy and you might even be producing something. But just to stand back a little bit and get out of the Sunbit thing, you got to stay rejuvenated. You have to stay excited and enthusiastic because patients feel that, oh my God, they can feel that if you're not happy and if you're moving around and you're a little more curt and abrupt. So, I would say to stay rejuvenated, you'd need to take a little bit more time off.

So, how you might solve that is you might have a partner and associate. And by having staggered schedules, you might be able to cover six days a week. I will say that when I was young, I was working six days a week, but I got off that very, very quick because I realized a lot of people wanted Saturdays. It was their day off, and then they didn't show up. Okay? So, I was sitting there with my whole team. So, then we worked five days a week for several years. And I decided to go to four. The whole staff, we decide, let's go to four. When I went to four days a week, we didn't make a single dime less than we did working for five days a week.

So, you think you have to be there. You make this stuff up, you practice it in your mind. I got to. You think you have to be there. You make this stuff up. You practice it in your mind. How can I lose a whole day and keep the same level of profitability? You have more juice. You have more energy. The staff has more energy. You might get one more patient in there every day and it makes it up.

All right. So, just to summarize, these five things on the list tend to be things that high growth practices are doing. However, and this actually sets them apart from struggling practices or maybe stagnant practices, but I do want to point out too that these high growth practices also tend to think a little bit differently. They have a different mindset. So, maybe you explain this a little bit more. What are their priorities?

Well, I think if you really care and you know you're really into delivering a product, dentistry, then I think what you might want to do is be modern. I won't mention names, but there are—they're my daughters and they're on this set. They stopped going to a dentist at one time just because it was too old-fashioned and they had gone to another office and seen digital. They've seen this, seen that. So, you want your carpets to look good. If you're doing carpets, you want your furniture, you want the walls painted. I mean, you want the modern look.

When they go in the back room, it should be clean, it should be organized. It should be really high tech and it feels good. They don’t even know what it is, but they know, wow, this is a—this is really important stuff. I was just recently in the hospital, not for myself, but for a friend. And it was amazing to see the modern surgery suite. Okay? And then, all the ladies and the patting on the back and the love, you could feel that.

So, the other thing is they want the patients to have great outcomes. They want their patients to get the care from the doctor. And then, they want that to be predictably successful. And so, the modern office, predictably successful treatment. And then, we want to have offices that optimize our time. When we're there, we want to be working. And we don't want lulls, and the staff can help. And with AI, you can tighten your schedules. And there's all kinds of tickler systems that you can use to make sure the doctor's busy.

And then finally, I think we all want to feel like we're on the cutting edge. I mean, who wants to say, gee, I'm going in there today and we're going to do it just like my grandfather. He was a dentist and my father was a dentist, and my grandfather was sitting on a piano bench. I mean, when you're doing something state-of-the-art, you feel good about yourself. And by going to meetings and talking to other people, you can tell kind of what's going on in the field. You want to like, keep going.

All right, well, great, thank you. So, we're still pretty early in the new year and if you felt like your practice didn't grow as much as you had hoped last year, well, we just identified five things that high growth practices are doing to be successful. So, even if you don't want to do all of those things on the list, trying one or two can't hurt, right?

No, in fact, I'm going to say it's synergistic. In my life, you know, you think, well, I'll add this, and I'll get a little bit better. And if I could add this, I'll get, of course, linearly better and maybe another linear curve. You know, when you start to put these things together, there's synergism. And the sum of the parts, or the number is greater than the sum of the parts. So, if you get one or two things going, round of applause, be comfortable, bring the staff along. But if you can't do technology, why are you trying to do it? You're stressing the Hell out of yourself. So, I would say hire us, you know, highly—okay, I was in Dr. Sherilyn Sheets' office and we were having an Innerview meeting and all of a sudden I was whisked into a room and I was going to have my Innerview test on all my 28 teeth. And I didn't even know we were going to do that. So, this guy comes in, he's the tech guy and we're talking, well he fixed the camera last week and the week before that, lights didn't come on in some surgical suite, fixed that. I mean this guy's Mr. Fix It, and he's also dental assistant. So, I mean, you could get that kind of person.

You hate insurance? Well, don't bring your wife in or, you know, bring somebody in that's really experienced. They know insurance companies. They know codes. They know what will be dumped by the insurance companies. So, mitigate those and file it, submit it right. So, do that.

And what else can we do? Hire your greatest weakness. It's always the case. We're not going to be good at everything. And as it's gotten more sophisticated in life, more technologically complex, find what you're masterful at, what you like to do and get rid of all the rest. That's called delegation.

Definitely put a team around you that's going gonna make you successful.

That's right.

All right. Well, thank you for that segment and that’s it for now.

All right. So, you’ve all been practicing for quite a while. You finished 2024 and you're looking ahead. So, I want to look at something we can do together to make life a little bit easier. We can learn from the past. So, when we look at pretreatment, I'd like to delve a little bit deeper into it because oftentimes that's the difference between success and failure. If we're trying to do endodontics and have reservoirs of irrigation and not have saliva coming in, blood might be seeping in from some electrosurgery or whatever, these are nuisances, distractions, and they compromise treatment.

So, whether we have a tooth that's broken off at the gum line or even subgingival, whether we're going through a really lousy provisional that's leaking, or whether we're going through a carious lesion that maybe invades into the pulp, or maybe you're seeing a fracture across the distal marginal ridge of a molar, these are the whys of why you might want to consider doing some pretreatment.

So, let's look at this case as an example, and this is for a partial denture. So, it's gonna be the terminal abutment for a partial denture. So, it's a strategic tooth. They could have had implants, they could have done all that, but the patient wanted to try to save this tooth and save their partial denture. There was massive caries under this. They went to the general dentist on an emergency. They had swelling under their tongue, okay?

So, this is a big lesion as you can map it. It may be even a thickened PDL. That's a massive lesion. You can see the mandibular canals cutting through there. You can kind of see a little bit in here. So, they had tingling in their tongue. They had all the things you might suspect when there's pressure on a major vascular, neurovascular bundle. And this is my pre-op.

So, the general dentist got him on antibiotic, got the swelling down, and cleaned out some caries, took off swelling down and cleaned out some caries, took off a bridge, cleaned out some caries. And he said, I'm just gonna leave it cause it's really messy. It's broken off sub-gingival. If you look very carefully, you can see the halo of white there. You can see it again on this side, barely, I'm close to the board, but this is all gum tissue, gingiva, all right? So, there's not very much that I can see, because a lot of the tissue's grown over the tooth and even over the provisional.

So, let's look at some things that I've learned over the years, things that you're doing too. We'll look at it together. Here we go. So, on our armamentarium when we're doing pretreatment, you don't need a lot of tools. If you have an electro surgeon, most general dentists, endodontists used to have them. A lot of endodontists now have lasers. Some of you general dentists, in fact, more general dentists have lasers than endodontists use lasers. So, I'm thinking there's lasers out there. In fact, I know from the Cao Group in Utah, there's 30,000 diode lasers alone in North America, more like 50,000 worldwide.

So, overgrown tissue can be removed with a laser. It's a diode laser, solid state, 8-10 nanometers on the electromagnetic spectrum of light. So, that's going to mean less blood. You're going to have coagulation immediately, like electrosurgery. So, we can do this to trim off, obviously, overgrown tissue. How much can you take off? Well, you can't just keep going, can you? Because there's the biological attachment and we need that biological width to the bone below that.

So, you can, not in maybe this case, but we can consider either doing it ourselves or sending it off to a periodontist where they can do APD reposition flaps. They can do osseous recontouring, then put the tissue back down on the bone. And you're going to have something to grab if you're a dentist doing endodontics.

So, crown lengthening is a very, very valuable procedure, not just to set up endodontics, but crown lengthening is a very, very valuable procedure not just to set up endodontics but it's going to help you get a better impression. You're going to land your margins better when you're doing your crown preparation. It's going to help the laboratory. All the subsequent steps from start to finish are going to be facilitated if you have a good crown that you can isolate.

All right, what else? There are a lot of matrix systems. Obviously, Tofflemire is the one you think of frequently, but there are all kinds of newer types. There's different kinds of bands. They can be cut with scissors. They can be trimmed. There's other bands you can buy off the shelf that will reach deep, where you need to get down deep. So, just, I'm not gonna teach Tofflemire. This is your bread and butter. For general dentists, you're doing caries control all the time, crown preparation. So, you're using electrosurgery, you're using lasers as I mentioned, and you're also doing crown lengthening occasionally and you're using matrix all the time like the sun comes up in the east. So, I'm not going to go beat this to death, but we'll show one. There's wizard wedges and different things we can do to really snug that band in to match the contours of the crown way down in those deep boxes.

All right. And what else? You're going to think about doing cores and buildups. Back in the old days, we did a lot of amalgam buildups. And I might say, having practiced for so many decades, they hold up really, really well. But with the rush internationally to, you know, move a little bit further away from amalgam, everybody's gone to adhesion dentistry. Incidentally, we could actually bond amalgam in the 70s and the 80s, we did.

So, bonded fillings come into mind, and you're gonna do a lot of the core buildups with composites and glass ionomers and things like that. So, bear in mind, you'll have your favorite matrix systems. I know you have them already. You'll have your favorite buildup materials. And I know that if you have these ideas and you're gonna do some endodontics, you can set these teeth up to be successful. So, success by design.

All right. So, if we push in, you can see these are nasty roots. I can't even see where this one ends. You got another vector on another one that comes down around like this. We have a distal root that looks like this but notice the canals coming down. There's blow out, pop out, push out, resorption. And when you have a case that's complicated, and it's the most venereal tooth in the most absolute way, you want to really know you're gonna be on this case for some time. There's curvature, there's resorption, there could be a lot of bleeding, or there would have been at one time, but now the lesion's so big, antibiotics perforate out to the lingual/sublingual, tongue was elevated a little bit in the mouth. So, there was a lot of concern with this case. So, you want to set it up so you can really be effective.

So, what I did back in the day, I was doing some research over the last month, just looking at this and I talked to Gordon Christensen. He's probably North America's most famous dentist. And copper bands really aren't available much anymore. When I went through grad school and all through the first two or three decades of my practice, I had copper bands that came in half sizes. We could get them at different thicknesses. I like the 0.005, but you could get them either 0.035. That means they're very thin. You can get a band that's too big and drop it over the tooth take your hemostats and squeeze it and pull it in and pinch it and then put your build up in that and then you can trim all that surplus off.

But you know what, think about the old days when we used to anneal them. So, we would get a pretty soft band. We would go ahead and run it through an open flame, Bunsen burner, until it turned cherry red, and then we could quench it. And when we quenched it, it became more malleable. And when it became more malleable, we could actually shape it to the contours of the tooth so we'd have a better fit. And then of course, if you let it cool down to room temperature, naturally, it'll actually give you a little stiffer band. So, we learned how to anneal the bands and work hard in the bands so that we could really get a good fit. And once you have that, then we can go ahead and we can place our bonding agents in here. And I did a big buildup. That's what I did in that day.

Now, that you have your circumferential matrix, and you can cut off the top of it so that when the patient closes down, it's not premature. It's also going to protect the tooth, you can provisionalize the tooth if it takes more than one visit. So, all these things are just added value after you get them on. And if you do a few of them, you'll get really good at them.

And if you don't have a copper band, then we're going to do a Tofflemire, a matrix and do buildups. So, it'd be much the same. So, you can go from the copper and say, I can’t get anymore. Or you can just go to a Tofflemire and do what most of you are doing today, and that's using tooth color restoratives and you're doing build-ups with that material.

So, now you have reference points that are going to be very accurate You're going to be able to isolate the tooth. There's going to be no salivary invasion. No blood. And It's going to make endodontics more restful, more fun, more delightful. And of course, we're talking about doing this. So, we're not really talking about clean and shaping today or negotiating canals, but you can see these canals are pretty curved and the files demonstrate that really wonderfully. Even getting through the resorption defect was a little bit tricky because as I just started to clear the pop out resorption, you know, the file can hit over on this wall, can hit down on this wall. It's three dimensional in there, but finally you can catheterize and get to the terminus and then establish patency.

And when you get to the terminus, move that file up and down a little short half millimeter strokes, 100-200 times, right, because you're just going to make the foramen a little bigger a little bigger you're going to get a little bit more transition in here and it's going to be easier to slide the next file through the resorption defect to the terminus.

All right. So, now that you got your shape going, you can go ahead and pack that thing. I left post space and the distal. You could stub restoratives into the ML and the MB if you chose to but I gave that choice to the general dentist that referred me the case. And you can see we've got a really nice fill, we've got accessory canals, very complicated anatomy. I think if you just look, this is day one, my pre-op, and if you look maybe a few weeks later, you can already see the ossification. You can already see regeneration of bone. If you change the biology, healing begins, as I said over and over, in four days. So, healing begins in four days.

All right. And here we are with a new restorative. This is, I don't know, several years later, but you can see the big lesion, the bones filled in perfectly. You can see the mandibular bundle coming through here now quite nicely now that we got the radiolucency eliminated. And so that's an important tooth the patient's through. She has a partial denture that snaps in and that's keeping that denture from flopping around there, because it's tooth born.

All right. So, that's one idea on really, badly broken down teeth. And I have seen hundreds and hundreds of them. And a lot of times you're going, I'm maybe not so good at it. It's going to take quite a bit of time. I don't think I can charge the insurance for it. You're starting to think about all these things. And just remember, suck it up. Do it. Because it's going gonna really save time on all the subsequent steps. And then, you're gonna have something that you're confident in. And when you refer it back, if you're a specialist, the general dentist is gonna be very happy to receive a tooth that's that easy for them to go ahead, run the burr around, make the impression, stamp the impression, you got it.

All right. Now, a lot of people will provisionalize teeth for the endodontist and this one happened in a kind of a funny way, I'll tell you about it. If you look carefully, there has been an attempt at access. If you look really carefully you can see it's quite black in here, and you can see there's a line here. So, as they drill down into the tooth to get to the roof of the pulp chamber—to get to the roof of the pulp chamber, the patient was hopping around the chair, even with their lip profoundly numb to the midline. In other words, they need supplemental anesthesia.

And so, the dentist told me, I gave you a piece of cake. I normally do these, but he said, I just couldn't get them anesthetized. But I gave you a provisional. You'll be able to work through the provisional, Cliff. I'm setting you up. Piece of cake. Well, the only problem is this provisional is leaking. Fluids are coming in under the margins. Fluids are invading. I can't do endodontics through that.

So, sometimes I said, we'd do them when teeth are broken off at the gingiva or subgingival, Sub-G. Sometimes you might think it's provisionalized, but it's not really provisionalized because it's not going to stand the test of all the steps you're going to do with start to finish the endodontics. You're going to be battling leakage. This provisional looks pretty good to me on the anterior abutment.

Okay. So, what do you do? Well, I gave supplemental. I gave an ILI, an intraligamentary injection on top of the usual mandibular block and I could isolate the tooth. We pulled off the provisional and this is just an orthodontic band. Okay? So, I said you can't get a copper band maybe, you might in other parts of the world, but not in North America, but you certainly could get orthodontic bands. And I have whole trays of bands by half sizes for every single tooth in the mouth. And you might have four or five different size bands per individual tooth. So, you can typically find, you or your assistant, your registered dental assistant can typically find a band that conforms quite nicely to that tooth and that's the one you're going to select and use.

So, once you get this, I again have reference points. I can provisionalize enter appointment. I've already gone in and done the pulpotomy so visit one was kind of an ascending emergency because they were hurting. So, I didn't have time to really get going with all the steps of endodontics but it was to get the provisional off, stop leakage, get into the pulp chamber, and live to fight another day.

So, this is my next visit, and I might just have you re-look at the endodontics that lies ahead. That's roller coaster anatomy. Those roots are, you know, they're meandering through multi-planar curvature. And remember the canals are more curved than the roots that hold them. So, you know, boom, we got one file in there to link that I've done quite a bit of body work in here to facilitate slaying a small size file. In this case, it's like a 15. So, if you learn how to work a 10, you can make any canal equivalent to a 15 with a 10 file, but that's another lecture another time. I hope a lot of you are watching the continuums. They're over on Ruddle Plus, and we go through these steps in very step-by-step manner and detail.

Okay. But you got that distal. So here we are snaking around. If you do a tangent line pretty much to the file, pretty much to the end of the instrument, you're approaching 90 degrees. So, that's a pretty good curvature. And again, the reference points I have a big reservoir of sodium hypochlorite. I can flush well. We can—if you have Gentle Wave, you're gonna have a platform. If you use lasers, you're gonna have that chamber. You know, it's just gonna help everything.

So, there we are getting our shapes going and that allows us then to go ahead and do what I think are appropriate root appropriate shapes. You can see the buildup in here, brand new crown, new bridge is in, patient’s happy. You know, we're always working on doing things that are more predictable, doing things that make patients happy, do things that are efficient, right? And do things that are modern. So that's just a little journey, taking something like this and ending up with something like that. That's a service. That's worth a fee that pays you and the patient pays with gratitude.

Well, I said we take on teeth that are broken sub-G. I said we have sometimes referrals that our patients come from other areas of the country or states, and they come in with provisionals and they're leaking. We've talked about that now. I could show hundreds of them, literally hundreds. And then, we have people that come in and they just have massive decay. And you know, it's kind of interesting when you say, well, when was the last time you saw your dentist six months ago? So, you begin to learn a lot about things. What if they said, I hadn't seen a dentist for years? We were thinking, of course that happened.

What I'm talking about for those that just woke up and they've never done endodontics in their life and they don't know what decay means, caries, you might know, I'm joking, we have a massive blowout underneath the filling, the restoration. So, pretty much you can see your pulp chamber in here. A little black area and the canal has come off of that. So, experience tells you you're going to probably clean that out and be in the pulp with vital pulp therapy coming more in vogue these days. There's more people taking out deep caries and pulp capping. Some people are doing pulpotomies. I won't be commenting on any of that today, but just be aware you're going to be close to the pulp if not overtly in it.

So, we talked about Tofflemires, you're looking at one. There's a myriad of different bands that you can select. Some of these bands, as I mentioned, can be trimmed with scissors so you can get more deep reaching and keep the rest high, as you push down on the more distal extension of that band as you push it down, because you got to be on tooth structure. You got to have that band meet the tooth and it needs to meet it. If it doesn't meet it tight, we can slide a wedge in here. And these wedges will push the band up tight against the tooth. We can use a ball burnisher to push the top of the band back out.

Remember I talked about heating and annealing? That works really well. So, you can actually contour and have a custom band that was, you know, like it was made from the factory for that patient's tooth. And since there's only about 6 billion people and they all have 32 teeth, oh, you can see there's a lot of bands out there. If you believe that, you'll believe anything I just told you.

All right. So, we're joking, but we're saying good, get good adaptations. Come around here and you can see, we see a little red in here, a little bit red. We're into the pulp, you know, it's gonna be looking like this, right? So, we're in there. And so, now we're gonna go ahead and place our buildup. I put bands around my buildups, people. I have seen a lot of teeth from others crack during treatment. We call those interappointment fractures. So, even with a nice buildup, you're going, but it's adhesion dentistry, Cliff. I'm bonding, I'm strengthening.

That's fine, but you're probably not doing the crown that afternoon, are you? So, they'll probably go home. And I know it's bonded. And we can get into whole things, is it really bonded? You know, you can bond enamel perfectly. It's a little trickier. General dentists know perfectly. Dentin has a lot of moisture. We start to see bond delamination. We start to see buildups that can just pop out with a spoon. So, when you talk about bonding, okay, I'll be with you on the conversation, but I understand bonding can fail and it doesn't always get a great seal.

So, I like to put bands around the buildup to hold everything together like a belt goes around your waist to keep your pants up. Gee, I sure hope my belt doesn't fail today. So, I have my cotton pellet in here to hold my position. I have a provisional up in here. I have a huge buildup in here. I'm ready to go. I'm ready to go. And we'll just slide it over one more time and then you can get in here and find MB1s, MB2s, Palatals and DBs. Notice the little re-curvature, okay, so you got your MB2. Notice it goes up and then like that. And then, we go right on around a decreasing radius curve. And the shapes again are appropriate for the root. All these roots are multi-planar, so we need to have flexible files. Heat treatment comes to mind. And all the fun you can have with a big reservoir for 3D disinfection.

Okay. Well, the last case I'd like to talk about is a case that is consuming the international community of dentistry. And, you know, everybody's talking about fractured teeth, everybody's talking about cracks. There was a very interesting article, it's on the discussion forum, it wasn't really an article, but it came from an article and it was talking about fractured teeth because it's a common discussion on the endodontic discussion forum. And of course, everybody's talking about the fractured teeth. What's the extent of the fracture? What do we do? Do we bond? Risk versus benefit, extract a tooth, do an implant.

So, there's all these ongoing discussions. We never seem to get consensus on, okay, there's lots of cracked teeth, but why are we scratching our heads still? There are protocols to follow. But the thing I wanted to show you is the clinical picture. You got a class one gold inlay in here. And I just made my conventional access into a necrotic tooth and you can see maybe a hint of something here. I'll go parallel to it not on top of it, or you won't see it.

Then you see something here. Up the axial wall, across the box form. And then, over the distal marginal ridge. So, you see the crack perfectly. So, when you see that, are you just going to go ahead and finish your root canal? Because you could say, geez, I can temporize, I have reference points, everything will be fine. Tell the patient to be careful, eat over on the contralateral side, favor this tooth. But when people get comfortable, they forget because they've already bit on this tooth millions and millions of times over the decades. So, we're creatures of habit. So, when people are comfortable, they return to the habits they are accustomed to.

So, the thing I want to pull now from that discussion forum, it was a very interesting comment by Al Gluskin, who's at the University of the Pacific in San Francisco. He's Department Chairman of Endodontics. Gluskin loves anthropology. And he was—he finally got on the forum and he kind of did one of these proverbially admonishments to the profession. He said, are you not—nobody ever—nobody ever discusses the opposing tooth. Ah, it's the plunger cusp of the maxillary molars that comes down and pounds on those steep incline planes of the mandibular teeth, pounds on mesial or distal marginal ridges. There might be, in different excursions of the mandible, there might be interferences, you might be right on those incline planes. They're wedgers, they're hammers, they're anvils. Are you the anvil or the hammer?

So, he talked about reforming the plunger cusp before you go ahead with endodontics on the opposite tooth. Did everybody hear that? That was a very valuable tip. That's something I'd been aware of for years. We were taught that at Harvard, but I thought everybody knew that. So, when Al said that publicly, I thought I would share that on this forum with you.

So, anyway, there it is, there's the crack. So, bands go around these teeth to protect them, inter-visit and interappointment so that we can get them back to have the tooth prepped, an impression, chew the cusp, grab that tooth, communicate to your patients, but it doesn't probe, the bone looks good, we don't have any, one of these infrabony pockets developing. So, it's with cautious optimism that you proceed, but it needs to be restored, and more importantly, needs to be protected.

So, there we are again, throw an orthodontic band around it, you can get the size it's almost like press it on with your thumb and cement in place and now go back in and do your endodontics and you can play curvatures, you can get that little bifidity down there at the deep, emerging systems split apically, right below the mandibular bundle, okay? So, you wonder why sometimes little lesions, they got radiating pain up to their ear, up to the temple area in their neck, okay? A lot of times these are vital inflamed cases and the bundle is in proximity to root ends and so you get that.

All right. So, we've gone through four types of reasons why you would do a band and when you would do a band, and even to some extent how you would do a band. And I'll leave you with this. This is really important. That's why it's in red. Take the time to do it. There's other components of our show that maybe we'll talk a little bit how you might be able to charge for that so that you feel like you have time to do it. But certainly, explain to the patient, it's hard to do endodontics, what I used to call submarine endodontics, where moisture and water is just pouring in.

So, turn the pretreatment, turn it into a breakthrough. It's gonna be tough, it's the breakdown, but like the hand, there's two sides, breakdown, breakthrough. And then finally, you're thinking it's so impossible, I won't get paid, there's no insurance to pay for that. The patient will never go for it, it's impossible. Remember, remember, I'm possible. Same spelling, just needs the apostrophe. Thank you.

Okay. So, we're going to close the show today with some more demotivators. And we just love these cards. We've been doing this since the first season of the show and if you don't know what they are, they're cards that look like this and they have a nice picture and a saying and then they have a little explanation below. And it's a little bit sarcastic, a little funny, but I think it will help you going through this new year to have a healthy mindset with a little bit of sense of humor about yourself too.

So, we're going to do this now. The first one that we're going to do today is called Wishes and it looks like this. It says, when you wish upon a falling star, your dreams can come true. Unless it's really a meteor hurtling to the earth which will destroy all life, then you're pretty much hosed no matter what you wish for, unless it's death by meteor. So, maybe you can comment on this.

Ah yes, so I'm looking up into the sky and it's normal to make big wishes and have aspirations and dreams and be sure that you during the subsequent year you know you try to convert those dreams into realities, but in the process, don't stand out in a hailstorm and kill yourself.

Yeah. As you go into this new year and we talked earlier on about having a correct perspective changing it from a negative perspective to a positive perspective. Just make sure your perspective is kind of realistic. So, just keep that in mind. All right, let's go to the next one. All right. The next one is, you are special, and it looks like this. And it says, if you require additional affirmation, get a puppy. The rest of us are trying to work.

Well, the cute little dog, the puppy. Yep. You are special, aren't you? We're all special, right? God made each one of us special in our own way. So, in all of your specialness, don't forget to work. And this reminds me, if you think you're a little too special, then maybe remember the slogan, buy a dog, name it Life, then you'd have one.

Yeah, I kind of am thinking sort of like maybe you're feeding the good wolf by just telling yourself with internal conversation that you're special and you don't need to hear about it from everyone else all the time. So, that's kind of what I was thinking. All right, let's go to the last one now.

We've probably all seen the little puppy in an office. Every office has one person that's really special, right? And they're not quite picking up the pace.

Right. All right, the last one we're gonna do is called Believe in Yourself. It looks like this. And it says, believe in yourself because the rest of us think you're an idiot.

Okay. So, it's normal. It's fact healthy, I think, to take some calculated, the word was calculated, risk to overcome your fear, to reach your full potential on this earth and to become your very best version. In the process, though, of doing all these risks, maybe you should chart the kayak trip first before you go over the Niagara Falls.

Okay. And this makes me think a lot of times in sports, whenever they're talking to some sports person that's very successful, like a common story is, no one believed I could do it. I had to believe in myself, you know? So, that makes me think of sports a lot. We just had the Super Bowl, and all season long I've heard them talk about Jalen Hurts just didn't have what it takes to be a Super Bowl champion. And then he—but he believed in himself and now he is the Super Bowl champion.

MVP.

Yes. So, that's… any other last comments?

No, go for it. But keep your paddles in the water.

Okay. Well, that's our show for today and we’ll see you next time on The Ruddle Show.