Broken Instrument Removal Why Files Break & the Ultrasonic Removal Option

This episode opens with a discussion about the science of music therapy and the importance of music in our lives, along with a guitar performance by our friend and colleague Dr. Rik van Mill. Ruddle then goes on to discuss why files break and the upset that this can cause. Next, he will show you the most common way to remove a broken instrument utilizing ultrasonics. The show closes with the return of our popular segment, What Phyllis Thinks!

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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: The Science of Music Therapy

Lisette

Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing today, Dad?

Cliff

I’m doing terrific, and I’m glad to be here on the set again, doing a shoot. So, what do you have for today?

Lisette

Well, we’re gonna start off talking about music therapy and the effect that music has on us. Music has played a central role in most cultures for centuries. In ancient civilizations, people used music to communicate with their gods and nature, as a healing tool, and also as a way to socialize. Then after World War II, doctors learned that music could help soldiers recover from the emotional and physical trauma of war. And then, we all know that music can have a very powerful effect on our emotions and our memories. But can you tell us, what is the science behind the positive effect that music has on us?

Cliff

Well, from a pharmaceutical standpoint, we have some good things that happen when we listen to music that can provoke different emotions, like Lisette was saying. But dopamine is one of them. It’s a hormone. And when you listen to things that really take you to great imaginations and highs in your mind, you do get a mood elevation, and you do feel happy. Immunoglobulin A, IgA, it’s actually a cell that attacks viruses. That would’ve been nice to know, maybe, in the COVID era. Maybe we should’ve listened to more music. But it can actually produce more of these cells that attack viruses. So, it strengthens our immune system.

Another real good benefit of music is cortisol could be lowered. Cortisol, as we all know, is a hormone related to stress. And it can be very dangerous if we’re operating with high levels of cortisol, all the time. But if we can lower that through listening to music, which music does, then, we handle stress better, and we – patients and you’re bringing it back to medicine, soldiers healing better, our patients will heal better. I think the last one would be – I think it was dopamine and go to endorphin.

Lisette

Or – no, you – what about endorphins?

Cliff

And endorphin’s a hormone. So, I was tryin’ to tie the hormones together. So, we have the endorphin and the dopamine. Endorphins is probably your classic hormone that’s released that can give you euphoria or levels of euphoria. And of course, it blocks pain. And that’s the big one. It prevents the neural transmitters from doing their job, transmitting pain signals. So, we can have a lot of benefits from that. You were gonna say something about blood pressure, maybe, and heart rate?

Lisette

Well, we’re very rhythmic, as – our bodies are very rhythmic, as well as music. So, if you’re listening to music that is more relaxing, you’re – you – it could lower your blood pressure, it could lower your heart rate. And this is good to know, because we’re all dealing with a lot of stress during this time, with the state of the world as it is. So, you might wanna think, in your office, in your doctor’s office, that maybe you wanna play music that’s more like stress free and relaxing, to create that relaxing environment.

So, we’re gonna show you now a video of a friend and clinician, Dr. Rik van Mill, from the Netherlands, and you also saw him, he was on one of our COVID Special Reports. But in the video we’re gonna show you, which is narrated by his wife, Wilma, it’s – we’re gonna show Rik playing the guitar to relax himself. So, can we see that video now?

[Video] [Guitar playing] So, now, at the moment, we are here on the second day of the seminar. It’s Saturday morning, around – little bit before 8:00. I’m preparing for lunch later on, and Rik is relaxing himself, little bit, by playing his guitar. He does that more often, just to relax his fingers and because he likes to do it. [Guitar playing] [End of video]

Well, that relaxed me and elevated my mood. How about you?

Cliff

I thought the setting was remarkable. And then, with the music itself, and then, from a friend, it sparked my imagination. I felt a higher level of reverence for humankind and a great respect for human potential.

Lisette

And incidentally, we will see more of Rik on our next season, too. So stay tuned for that. So let’s get started with our show today. We’re gonna talk about broken instruments. We’re gonna talk about why instruments break, the upset, and how to remove them using ultrasonics. There’s other ways to remove them, but we’re gonna talk about the ultrasonic option today. So, let’s get started. [Music playing]

SEGMENT 1: Why Files Break

Lisette

So, for our first segment, we’re going to talk about breaking instruments, why they break, and the upset that this can cause. During root canal preparation procedures, the potential to break an instrument in the canal is always present. And if any of you have ever broken an instrument, I’m sure you have felt frustration, anxiety, despair, maybe even a little bit of panic. It can be so disheartening, in fact, that clinicians often want to refer to a broken instrument as “separated” or “disarticulated”, instead of using the word “broken”. So understanding why instruments break goes a long way in preventing this upset. So, we want to start off today to focus on the anatomy of the tooth. Are there certain kinds of tooth anatomy that maybe can increase the chance of an instrument breaking?

Cliff

Absolutely. The first thing I guess I would think about is to refer people to the anatomy of a human tooth. Like in this case, this is an actual tooth. It’s been 3D scanned. And then, we’ve made the crown look more aesthetically, just for teaching purposes, but it’s a real tooth, with a real pulp. And the experienced colleagues would immediately understand that if you’re looking at this revolving tooth, you’re starting to look at maybe three variables, if – we’re not talking about files. We’re talking about anatomy.

So we have longer canals, and we have shorter canals. Longer canals are going to invite more fractures, because there’s longer engagement zones, and there’s more stress on the instrument. The other consideration is cross-sectional diameter. So, bigger canals, there’s less torque and pressure on the file, during activity. So bigger diameter canals are easier to navigate. I’m talkin’ about more restrictive, narrow, calcification, more mineralized canals. So we have the length, we have the cross-sectional diameter, and finally, we have curvature. So we can have curvature that are nice and gentle, we can have abrupt apical curvatures, and we can have recurvatures.

So when you’re looking at this anatomical tooth coming around, you might see even other factors anatomically that don’t fall within length, diameter, and curvature. And that would be, think of the tip of your first [with emphasis] instrument below the orifice. That tip could get hung up in a fin or an eccentricity off the rounder part of a canal, and that could also contribute to fractured instruments.

Lisette

Okay. So, you’ve identified the culprit tooth, and you’ve seen radiographs and or CBCT images. So, you’re kinda – know what you’re dealing with, and you start to open the tooth. But how does the access influence the potential to break an instrument?

Cliff

Have you done this before?

Lisette

[laughs]

Cliff

Access is – you don’t really think a lot of it, as a clinician, maybe, because I’ve been doin’ this for almost 50 years. And most clinicians never make the connection between broken file, access. But I’m glad you asked that, because if we get to access, you can begin to see immediately, you know, we got triangles of dentin, triangles of dentin. So, these canals converge into the floor of the pulp chamber and it makes for abrupt, awkward angles. So I’ve always taught to eliminate the triangles of dentin, so you have more radicular access. You talked about coronal access. This would be called the radicular access. So, we need two. So, “access” means, remove your impediments.

You know – I guess I can stand up. But if you imagine a file coming up out of this MB canal, the handle’s gonna be over here. That’s the access. So we have a lot more strain on the instrument’s coronally, where they’re not flexible, and they’re stiff. So, we wanna upright those handles, by removing the triangle, and get the handles on axes. So we speak about off axes and on axes. So access plays a pretty important role, and if clinicians just get their access right, everything else starts to go with the flow of the music segment.

Lisette

[laughs] So, okay. So, after you access, and you start to negotiate the canal, I know that – I’ve heard you say --

Cliff

Don’t negotiate the canal!

Lisette

-- [laughs] I’ve heard you say often, in your teaching, the massive importance glide path management plays. And I’ve also heard you say that often, when a canal breaks, that the clinician didn’t have a proper glide path. Now I know we’ve talked about glide path on a couple shows ago, and we also talked about irrigants. But can you talk about glide path and irrigants, in terms of potential to break an instrument?

Cliff

I would. Before I play this little clip, I’d like to set this up with – that’s a terrific question. I think it was show – second season, show four, about five shows ago. You can go back and look, but this season, for sure. And we did a whole medley on the reagents, okay? The viscous chelator, the sodium hypochlorite 6 percent, and the 17 percent EDTA. That’s the three things I’m using. And so, I won’t really talk about ‘em that much today, except to say what I’m thinking about. What I’m thinking about is when I put a file below the orifice, I’m going where humankind has never gone before. So usually, when you’re going [laughs] into places that you don’t have familiarity with, you might show a little more restraint. You might show more respect. And you might be wanting to do things that give you forgiveness.

So, a viscous chelator is an emulsifier. It’s a lubricant, and it keeps debris in suspension. So those three things, when the space is so narrow and so small, it’s really important to have that lubricant, the emulsifier that prevents vital tissue to re-adhere to itself, and now there’s no pilot hole, because it’s closed off. So, with – the chemicals are important. I also wanna talk about a concept that we won’t speak about much today, but if we pre-enlarge the canal, coronally, first, it will greatly reduce broken instruments, deep in the apical one-third. That’s not our comments today, but pre-enlargement’s a concept that helps you reduce iatrogenic events like broken instruments, ledges, blocks, perfs, that kinda thing. And it also helps you be more successful.

So, I’m going to start this little clip, because I did agree with you, 100 percent. The – you know, we’ll talk about the technical things later. I think you have a couple questions for me, maybe about torque and cyclic fatigue. But right now, it’s glide path management. And if you have glide path management, you can probably even use a file from 50 years ago. I’m just kidding! And it’ll probably be okay. If you use it with restraint, if you use it with delicacy, and you’re not trying to screw those instruments in. In sports, we used to say, “Let the game come to Cliff. Don’t force the play, Cliff.”

So if we let the game come to us, we’ll start the video clip, and you can see, your file’s up here. At this stage of treatment, you have – I’m just making this up. But in this case, we’re demonstrating a vital case, vital tissue, it’s collagenous tissue. So, what is in here? A lot of you think you are using sodium hypochlorite, right? So you have sodium hypochlorite, filling your pulp chamber, and you’re thinking, “It’s flooded!” Well, there’s almost nothing below the orifice. And if it’s filled with tissue, there’s zero. If it was open, because it was putrescent and necrotic, then, of course, when you put the file in it, what little irrigant was in the coronal part of the canal has now been displaced by the instrument. All’s you gotta do to prove this is just have a little grandson or something stick their fist in a bucket of water, and you see how much they displace.

So, there’s gonna be almost no reagent, and what little there is would be probably largely displaced by the file. So I’m really speaking about viscous chelator. So, if you begin to work, and you begin to activate the file, the file’s loading up with debris. You can see that perfectly. You can see as we come down across lateral anatomy, we can stretch it, pull it, and shred it. But then, watch our file. Our – even moving our file, debris is not only loaded onto the flutes, but it’s displaced into the irregular surfaces and the lateral canals and the dentinal tubules. So all these tend to serve to obstruct the file. If the colleague keeps torqueing and the end of the file is frozen, you can see that is one way we can see a broken instrument. This would probably be a torque failure, which we’ll talk about in a bit.

Anyway, glide path management, to your point, is critically essential. The thing here is maybe take the file out, get more viscous chelator in the pulp chamber. Don’t just butter your file. That’s cheating. Fill the pulp chamber with viscous chelator. When you pass the file through the viscous chelator, you will be buttering the file. The file will move below the orifice buttered, and so, maybe if the file’s not going, put in more viscous chelator, maybe go to an 8, maybe drop to an 06, but not this big motion. And you feel that pressure. I can’t teach that, but you know. You’re on the edge, aren’t you?

And if [makes ‘ch’ sound] you feel that, and your heart sinks, it kinda feels like the day’s over. And then, when you pull the file out, it was kinda like the cartoon [laughs], you know, it went in this long. “Oh, God! [laughs] Look at that!” So, yeah.

Lisette

[laughs] Okay. So, if you – so, we’ve talked about the anatomy, access, glide path management, the reagent. Now let’s talk about the files themselves, like what would cause a file to break?

Cliff

Technically, real easy. Two words, “torque” and “cyclic fatigue”. Torque, I think most dentists know, but just to review it quickly, you’re up here on the handle, doing some kind of a circular motion. Well, if the file tip or any part of that file is unable to move because it’s too tight, and you go one more quarter of a turn, that’s gonna be – the torque you put on the handle exceeds the elastic limit of a file, and you get a breakage. The other one I’ve talked about before is cyclic fatigue. If this is a file, then, around a curve, we have compressive stresses. On the outer wall, we have tensile stresses. So that’s like taking a paper clip and doing this repeatedly, till it fails.

So, when you’re spinning around curvatures, that would be an example. If you have an older example, a duller instrument, it might not be able to handle the cyclic fatigue. So, those are your two technical things. I’d like to make it easier. They break, in my opinion, because of method of use and multiple use. Method of use has to do with – you just saw it. We broke an instrument, because we were too aggressive, we didn’t have the right chelator. Maybe we should’ve done pre-enlargement, so we would’ve had a bigger reservoir of reagent. So, things like that.

There is heat treatment, and it’s not really a cause for breakage; it’s intended to make files have a higher resistance to cyclic fatigue. So, that’s a good thing. But then, there’s that balance between cutting efficiency and safety. So, it’s nice for a company to make a file and say it can spin for three, four, five minutes and not break. But it’s – when they do these tests, there’s no load. There’s no load on the file. The file is in an apparatus that makes it go around a 90-degree curve, and it’s spinning with no load. So, it can spin for enormous amounts of time and break [clapping]. Round of applause. Who cares? It really matters more when the file’s loaded.

So, heat treatment’s good, but then, people that use excessive heat treatment, we have a lot of unwinding. So, we have breakage from torque and cyclic fatigue, and then, we have unwinding a lot, because of excessive heat treatment.

Lisette

Regarding multiple use, it seems like, in this day and age, you would want to always be using new files, to, you know, reduce the chance of disease transferring. But also, I just – I mean, how expensive are files? Because if I was a patient, I would just want new files to be used on me. I mean, wouldn’t most patients?

Cliff

Well, I guess the best way to answer your question is with a story. [laughs] Course, I like stories. That’ll blow the whole timeline of the show, right?

Lisette

[laughs]

Cliff

So, I’d better go quickly. So, I always get this question asked, all over the world, in every lecture, and I have – before NiTi, I got ‘em, back when it was stainless steel. So, for almost 50 years, you get this question. “Cliff, how many times can I use this file?” “Cliff, can I use it two times? Would that be okay?” A length, diameter, curvature, I can’t remember all that. So, since there’s so many variables, even within those three, I was just trained in school, every patient deserves the courtesy and the respect of a brand-new set of instruments.

So, we’re talking as if we’re only trying to prevent breakage. But brand-new instruments have a cutting edge that is sharp. And so, they’re more efficient, and they’re less likely to break. As the dull blade tries to cut, and it can’t, we have to use more force. Now we’re putting more limitations on the instruments, in terms of its metallurgy. So, to me, the story was, I just asked a patient. I said, “Is this a doctor problem, or is this a patient problem? Is this about money?”

So, I said, to – for one year, every single patient I saw -- true story. Everybody I saw, when we got all of the pleasantries done, the blood pressure, all that’s taken, all the information’s gathered, all the data’s recorded, we’re gettin’ down to, like, scheduling, fees, time, prognosis. And so, I’ll skip those, except the thing we’re talkin’ about, I would say to a patient, “You know, for – we can’ – I’m just makin’ up this number, a root canal fee. “For $750, we can use some used files.” They’ve been sterilized, and they’re’ – I had ‘em in a little bag that you could see turned from blue to pink, which means it went through the autoclave protocol, internationally. So, we could reassure ‘em, lots of pats on the back.

So, $750, or you hold out a box of brand-new, pre-sterilized instruments, and you say, “Or I could use them, brand new, out of the box, for $800, $50 different. How would you like me to proceed with scheduling?” In one year, one lady said, “I’ll take the used files.” So, that’s hundreds of patients. Everybody said [laughs], like – they looked at me like I was crazy, “No, I want the new ones.” So --

Lisette

[laughs] So --

Cliff

-- it’s a doctor problem, not a patient problem.

Lisette

-- okay. So, we – obviously, you’ve given us a lot of things to think about, to prevent [with emphasis] files from breaking in the first place. But say you’re working along, and you think you’re doing everything right, and then, all of a sudden, an instrument breaks. And I imagine there could be quite a bit of, like, internal anxiety, maybe a little bit [laughs] of panic. Have you ever broken an instrument?

Cliff

Well, I was gonna fall off my chair, but that would’ve been --

Lisette

[laughs]

Cliff

-- too dramatic, and I might’ve gone the wrong way and hit my head and [bleep] it would’ve been all over. Yeah. I’ve broken two instruments in 49 years. One was in grad school, my second year. I broke a GG2 in the DB of a maxillary second molar, 3 millimeters below the orifice.

Lisette

[laughs]

Cliff

You don’t forget this stuff.

Lisette

Yeah [laughs].

Cliff

And of course, we got it out, but you could imagine, some of the words you used in the opening. That’s what the kid was feeling in the ‘70s. But fortunately, there was an instructor there, and he was very nice. I took it out, but he sat there, “Now do this. Check. Now do that. You don’t have it yet! Do a little bit more.” Check. And we got it out. The other one was deeper into my career by far, and it was – you know how they say, “Never treat a relative”? This was Phyllis’ father.

Lisette

[laughs]

Cliff

So, he’s coming out to Santa Barbara, especially to have me do a root canal on the posterior abutment of a four-unit bridge. No problem. So, he comes in, we take a film, and I go, ‘It’s gonna be interesting’, because the mesial roots had a sweeping curve. Looked like two systems. The distal went down about 16, 17 millimeters, made a 90-degree turn -- this is the root [with emphasis], not the canal, and went another 5 or 6 millimeters. I thought, “Well, Ruddle likes challenges. So, this is gonna be [claps] really fun.”

And I had it down – the whole case was finished, and I was fitting cones, MB, ML, piece of cake. The distal, I had it at length, but I saw it was a little wrinkled, dentists know what that means, a little crinkle. I thought, “I could – I can just do a little better on my shaping.” It wasn’t a cone fit problem. It’s a shaping problem that showed up as a cone fit problem. So, I went in with a 35. I was workin’ a little bit short of length, and I just smoothed it a little bit more, and [makes ‘ch’ sound], just like [laughs] – just like [laughs] that! Except it was over here. And let’s just say that, six hours later, I never got it out. I bypassed it. I fit a cone around it, and I entombed it within the obturation material. And he died many years, maybe two decades later, with the tooth in his head.

But those were two upsets. They’re so important in your life. You never want that to happen again. So, you always like a breakdown in hand, a two-side breakdown, breakthrough. So, you always figure out what happened, and put structures in place to turn the upset into the glide path to success.

Lisette

Well, I guess this kind of brings up the next question I have is like, say you do break an instrument. Then, how do you communicate that to your patient, without creating, like, panic, but also taking responsibility?

Cliff

You know, I can’t tell you, because of the – the one instance in Santa Barbara, one was at Boston, in grad school. But I can tell you, you talk the same way, because I have been referred thousands [with emphasis] of people with broken instruments in their teeth, and they’re upset! And some of them have been talked to properly by the general dentist, so they know why they’re in my office. They understand, with a lot of hope, that I can get it out, because maybe the stakes are high. Maybe it’s a posterior abutment in the most funereal sense.

So, what I’m going to say about communication is, if it’s you that breaks the instrument, or me, let’s tell the patient. So, I don’t mind if you fool around for five more minutes. I’m being serious. 5 or 10 more minutes, because you think maybe you can get it out, why even tell ‘em? Like if I break an instrument in your tooth, and five minutes later, I get it out, do you need to know? I’ll put it in my record. But it really has nothing to do with the outcome. But if you start fiddlin’ around 10, 15 minutes, do you think patients don’t know something’s wrong?

Because they’ve been laying there, listening to the music, and there’s a certain flow and rhythm going on around ‘em, and all of a sudden, you’re a little closer, maybe there’s a bead of sweat.

Lisette

[laughs]

Cliff

You’re asking for redundancies, and the assistants – they know, they sense [with emphasis] something is not right. So, try for 5 minutes or 10, but if you’re having trouble, get the chair up so you’re eye to eye, you’re not looking down at ‘em. Okay. Get the dam off, so they can talk. And just say, you know, “We’ve had an accident, and I’ve broken a file. And here’s the Y in the road.”

If you have the training, if you have the technology, and you have the experience, you can say to them, with a lot of confidence, “It looks like I can probably get this out, but we might have to reschedule.”

Lisette

Okay. So, it’s not malpractice to break an instrument. It’s just like a risk that could happen?

Cliff

Absolutely. In fact, we didn’t talk about it, and – in fact, you probably want me to talk about it. When you’re delivering your consultation, and you’re delivering the way forward with treatment, you have to communicate risks versus benefits. And I said “risks” with an S. So, one risk of endodontics is a broken instrument. So it’s never [with emphasis] a lawsuit that you’ll ever lose. I mean, you can get sued, but you’ll never [with emphasis], ever lose, if you’ve told the patient. Even if they’re angry as Hell. But you must write it in the record, you know, “Patient was advised.” Okay.

So, in our communications, let’s start, before we even break it, by paving our way with words, that it’s a medical procedure. It’s a surgical procedure. We’re amputating the incoming nerve and blood supply. So, okay? There’s risks associated with every medical or dental procedure known to mankind. Communicate it. Don’t overemphasize it. But it should be registered, you should even say in the chart, “Patient was advised of the procedural risk. Dr. Ruddle thought there was a chance to maybe – to separate an instrument, because the root curvature is extreme.” So, yeah. Say that.

So, now that it’s broken, either it’s gonna be you [with emphasis], that’s the Y in the road, or you might wanna refer. And a lot of times, there’s a lot of – it’s calming, sometimes, for the patient to hear there’s a choice, from a specialist. They could think, “Well, why didn’t you refer me there, in the first place?” But if you pave your way with words like, “Mary, I do a lot of these. They go well. We rarely have problems. Sometimes it – in a procedure like this, we could break an instrument.” Whatever else you’re worried about, communicate it. Assistants – they’re writing it all down.

So when you do say you will refer, they probably wouldn’t say, “Well, why’d you even start?” Because they – they trust you. They like you. That’s why you’re sitting there, doing a root canal on ’em. So be prepared to make the referral, and understand that you should call the referring endodontist, if that’s who it is. Don’t just send a patient over, walks in with a broken tooth in their mouth, because you wanna kinda control the story. And the story isn’t a lie, it’s the truth, but you want that doctor to say, “Great [claps] to see you, Lisette! I understand you came from Dr. Stu Sotto. He’s a fabulous [with emphasis] dentist! And he’s got an instrument in here he wants to see if I’ll look at, see if I can get it out.”

So already, it’s a much different environment than if I go, “Well, did you know you have a broken instrument in your tooth?” “What!? I didn’t know I had a” – so, then, you have a lot of problems. So, always tell the patient, write it in the chart, and then, do what’s right. And let’s finish this with Herb Schilder’s famous quote, “Make yourself the patient, and you’ll have the answer”, regarding to do it yourself or to refer, or to hide it and extract it.

Lisette

[laughs]

Cliff

Well, that happens, too.

Lisette

Okay. Well, so, say you believe you can remove it, and you have some experience. What technology – can you just run through us, what technology you should probably have in your office, if you’re going to attempt to remove a broken instrument?

Cliff

Yeah. We put it up, right here. You know, this is the – this is after it happened. So, what technology to get that out? Okay. I get it.

Lisette

Oh [laughs].

Cliff

Well, we have some tools, and the tools are quite basic. And they – you know, vision! You gotta see it. If you can – there’s the old adage, “You only know what you see, and you only see what you know.” If you can see it, you can do it! Okay? Any of those work for me. And then, of course, you come at it, “Of course, I can get it out!” If you think you can, you can, and if you think you can’t, you’re right! So, vision’s gonna be one of the most important things. Transillumination devices, overhead lights, magnifying glasses, those are all in the game, but they’re not a microscope, where you have coaxial vision. That means light and magnification equals vision.

CBCT. Course you have your periapical, two-dimensional films. Those are useful. But CBC tells us a lot more, and then, we can do the axial slides, and we can see how much root bulk and form we have. And then, of course, I really like the first option. There’s many things, as Lisette talked about, that we’ll, in future shows, discuss. Auxiliary methods, adjunct methods, when ultrasonics fails, but every device requires pretty much an ultrasonic intervention as an initial attempt. So we have some tips, and we have a handpiece. Notice that we have incredible vision. We’re not looking at the back end of a handpiece, trying to see around it. We can look right down a sleek instrument, and we’re going to watch the tips of these instruments work deep.

So, that’s going to be really important. And these instruments can be coated. This is zirconium nitride coating on, and Dentsply Sirona makes the endo series, but it doesn’t matter to me what you use, as long as it’s working. Then, we have titanium tips, the 6, 7, and 8, purple, blue, green. They’re longer, and they’re skinnier. You can’t make stainless steel coated and make it that long and that skinny. It breaks in the air. So we needed a different material. Not nickel titanium, titanium. And of course, when these instruments work, they create dust. So, it’s gonna be really important to blow this out and evacuate the debris.

So while we’re working, you know, we have our eye, have a mouth mirror, my oculars, my handpiece, and I have continuous vision. If I can’t see it, stop immediately. So, that would be your most important tools.

Lisette

Okay. So, you did say that there’s many ways to remove a broken instrument. And now, why don’t you just show us the most common way, which is the ultrasonic option?

Cliff

Well, okay. I’d better get rolling!

Lisette

‘Kay [laughs]. [Music playing]

SEGMENT 2: Removing Broken Instruments – Ultrasonic Option

Cliff

Hi, again. We just spoke about why instruments break. In this segment, we’ll be focused on how to remove broken instruments. So, whether you broke the instrument, or it’s been referred to you, to be removed, there’s several things we need to consider. And the things we need to consider are basically the things we talked about last time. So, just a quick comment: cyclic fatigue and torque failures would be the scientific reasons instruments break. But usually, it’s related to glide path or the absence of the glide path. And so, we did a lot of talk last section, the segment just before, on getting a good, smooth, reproducible glide path.

Now, when we have a broken instrument, there’s several things we gotta consider. First, let’s go ahead and get a good radiological exam. And this could be not only, then, just x-rays, but it could also be CBCT. And we’re gonna get pretty good vision of – on that axial slides, how much circumferential dentin we have around the instrument itself. So, really, the radiographic exam is critical [with emphasis], so we can begin planning. What are we planning? Well, where is the instrument located? What is its position in the overall length of the canal? If we can get access to the head of the instrument, we can even have an instrument lie around the curvature, and we still have a good chance to get the instrument out.

Obviously, when the instrument lies completely around the curvature, and there’s no opportunity to get radicular access and a line of sight to the head, then, obviously, there’s other ideas that we’ll talk about in other segments. And I’m talking about ways that actually work! And it’s not the old-fashioned bypass and instrument technique. New technology. So, radiographically and our CBCT are gonna give us the good glimpse. Focus on the anatomy of the tooth. So when we think about the anatomy, I’m thinking about not only the canal anatomy, but I’m thinking about the root anatomy. So, how much bulk do we have? Bulk and form.

In other words, when you know that there’s concavities, we know, if we do a cross-section through this root, we know – I’ll just get this a little cleared out for you. If we do a cross-section through the root, and we take a peek right in there, we know that that root is kidney-bean shaped, and the canals are a little bit closer to the furcal side. Because these canals make these awkward entry angles up into the tooth, and then, we can see the canals lie a little closer to the furca. So, we’re gonna wanna move the canal away from furcal danger, as we begin to think about how to get it out. So, where is the instrument located, relative to the curve?

And then another thing we should probably consider, and it might be one of the most important things we’ve talked about, is, if we did a bell curve of all the teeth on the planet, we could say about 80 percent of all teeth are about 19 to 25 millimeters in overall length. Well, why am I telling you this? Because it has to do with planning, so we maximize remaining tooth structure. So, about 10 millimeters of any overall length could be considered clinical crown, so, roots that are about 9 to 15. If you take your roots and divide ‘em into thirds, coronal, middle, and apical thirds, we could actually discover that each third is about three, four, or five millimeters.

So, now that we have that understood, we now need to know that roots that pretty much don’t break in the coronal one-third, you’ll have some break in the middle one-third, but dominantly we’re talking about challenges that lie at about the top of the apical one-third or into the apical one-third. If you look at the literature – if you look at the literature, basically, what breaks is about D3, D4, D5. So instruments can be – we can talk of instruments, you know, their tip would be called D0, and then, we can talk about D1, D2, D3, D4, whatever. Instruments break about D3, D4, D5. We just say the average is four.

Then, you can begin to see that even if it broke right at length, if it broke exactly at length, four millimeters up is gonna put you pretty much at the bottom of the middle one-third. Your question chairside is, as you analyze your diagnostic stuff, films and CBCT, is, “Can I make a careful access, down through the top of this canal, and can I visualize the top of the instrument without making the preparation needlessly over enlarged?” In fact, what is the size of the radicular access? What we should be talking about, then, is a preparation that would be no bigger if there were no broken instrument, okay? That’s a guideline.

So you’re looking at your anatomy on the tooth. Different angles help us see the in and out, buccal, lingual dimensions. The CBCT gives us great sections that we can see in the axial, sagittal, and frontal planes. And you’re about ready to have a plan. So what I’d like you to be thinking about is how to make access. Well, when a file breaks, obviously, there’s already some pathway down to the head of that broken file. You already have a pathway there. Even if you broke a 20.04, as a single example, if you broke a 20.04, 4 millimeters up, 4 times 4 is 16, and 20. So, you’re gonna add 20 to that, and you have, like, about a 36.

So, the head of your file’s about 0.36, in that analogy, which means, probably it’s going to be big enough that you’re gonna see it, and you’re gonna probably be able to develop the access down to visualize it. If you can visualize it, you can probably do it. There’s that old expression, “You only know what you can see, and you only see what you know.” So, let’s see if we can now get in here. Well, there’s many ways to get out instruments. I’ve written chapters in multiple textbooks around the world. I’ve written many clinical articles in peer-review and trade magazines. And what I can tell you is, there’s probably five or six ideas.

But regardless which idea you wanna use, we always do one thing, always, first, and that’s the ultrasonic option. This is always the starting point in the modern era -- that means since the mid-‘80s -- to get out a broken tool. And a broken instrument could be a lentulo, it could be the head of a Gates Glidden. A broken instrument doesn’t necessarily mean a file. It means an intracanal obstruction. Well, let’s talk about radicular access. Fortunately, you already have some kind of a tapered pathway down to the head of that broken file. But we have to really come back and look at that furca side concavity.

And because we know there’s that concavity, I prefer to use instruments that cut selectively over a very small distance. And that would be what? That would be your Gates Gliddens. But they’re not used like probably you were taught in dental school. I’m gonna show you a little different way to use them, for control and selectivity. I want you to remove dentin in very precise regions. When you put a NiTi file in here and try to improve your shape, you’re gonna be cutting over the whole distance, most likely, and that means there’s not much selectivity. And so, we can do something with the head of a Gates Glidden 4. So, so you’ll know, the 3 most frequently used in crown-down, 4, 3, 2.

Let’s look at these a little bit carefully. So, if you look at it carefully, you’ll notice that we never go more than about one bud depth below the orifice. I don’t care if you’re in – tough ones, okay? Buccal systems of upper molars, mesial systems of mandibular molars, that’s where we have tougher canals, smaller diameter. They come in at that awkward entry angle that I just spoke about, and so, we need to get access. So that would be about 1.1, and we would use it like a brush [with emphasis]. Okay? You’re not drilling into teeth. You’re brush cutting! Say, “brush cutting” to improve your performance. Think of it as a big hairbrush.

Well, if you got that down, then, we’re gonna go about 1 bud depth below the 4, and we’ll go to the 3. The 3 is 0.9. It’s another brush. And we’re always brush cutting towards the greatest bulk of dentin. And that’s away from the furca. We wanna stay away from furcal danger! Okay. So, always brush cut out. You’d have more dentin out here. Now, some people go, “Oh, gee! What about this triangle? What if you take off the triangle of dentin? What if you take off the triangle of dentin?” Listen! Think ahead, to restorative. There’s been a whole movement! “Oh, the restorative end’s in mind!” We always [with emphasis] had that in mind. In fact, why even do a root canal, if it’s not a restorable tooth?

So, the concern is, by taking out the triangle, we’re losing precious tooth structure. We’re losing this area that’s called peri cervical dentin. Think of the restorative effort! Talk to Frank Spear, talk to John Kois, two of your experts. Talk to Cherilyn Sheets! We always talk about the circumferential ferrule! The ferrule is most important on the buccal and the lingual! The ferrule is less important mesial and distal! Because when we bite down and chew, we go into work and balance, the loads are on the buccal-lingual. So, you’re not going to remove a triangle and have to worry about compromising the ferrule and the strength of the tooth, post-treatment. Okay?

It’s good to review this stuff. So, the 4 is 1 head depth, the 3 is a little bit below the 4, and it works over a range, right in the middle one-third. And that gets us finally to the what? The 2, and the 2 is 7/10 of a millimeter. Most of your shapes – are you listening? Most of your shapes are about 7/10, 8/10, in the body! So that is appropriate, and it’s not too big. Boy, I love this board! I’m havin’ so much fun! I got stuff goin’ on! It’s like removing a broken instrument! So, I didn’t emphasize, I did not emphasize 500 rpms. You should see the flutes of the GG turn at 500 rpms. It shouldn’t be so rotational fast that it’s like a prop on a plane and becomes blurry, and suddenly, you can’t see.

So if you use them slower than you’re used to, in an electric motor, in a brushing motion, you can selectively cut right at the height of that belly. Right at the height of the belly is the big brush. And then, finally, you’re on top of the broken instrument. But think ahead! You’re going to bring an ultrasonic instrument down, kinda like this Gates Glidden 2. And when it comes down, you don’t want to be on top of the broken file. That’s not effective, and it’s not efficient! You need to be lateral [with emphasis], so you can trephine, and you can begin to expose the head of the file. So, if we can’t imagine coming down and getting lateral, in a rounder cross-sectional diameter canal, then we have to think about the modified technique.

Now, we talked about this in the late ‘80s. I got my scope in the late ‘80s, middle to late ‘80s. And so, all of this was new back then, and it had to be discovered. So what we decided to do is take a regular GG, and by cutting it, you have a modified GG. That can make a flap, and that flap means that you make space, a platform, a staging platform, around the head of the file, where you can set your ultrasonic-activated instrument, and by going counter-clockwise – by always going counter-clockwise, we can begin to encourage the broken fragment to unwind, loosen, and maybe jettison out of the canal.

If you really wanna get a little – little trick. I guess I’ll work a trick in right now, a little Ruddle trick. I have taken a Joe Dandy, and I have taken a modified GG, and I have scored it east to west and north to south. I’ve made a slot. So, I’ve made a slot here, and I’ve made a slot over on this side. And then, if you looked at the end of that thing, it would have a slot like this, and a slot like this. That slot, if you come back in here, sometimes that slot will catch the ragged part of the head of that broken instrument. And if you stay on that, as you’re rotating counter- [with great emphasis] clockwise, okay? This would be a counterclockwise rotation, in reverse [with emphasis]. You can sometimes get broken instrument out that way. Think about that! Not so bad, uh?

Boy, I bet you’re gonna break an instrument on your next patient, so you can see how this stuff works! Okay. You got a modified GG. So let’s put it all into motion. Now that we’ve done the technical part, and you understand there are sizes and how to use them, here we go. Now again, I want you to think of this as a brush. I want you to be thinking about pushing that canal – get that triangle out. Push the canal away from the furcation. And you can see, the flutes are loading, it’s very selective, you have a lot of control, it’s not gonna grab and get sucked in, because your 500, sometimes I’m working at 400, enough rotational speed to cut.

Well, once you’ve finished about 1 head depth below the orifice, you can go to the 3. The 3 comes right in. You got a big bath of sodium hypochlorite going, and now, right in this furcation area that we keep talking about, we wanna move that canal away towards the maximum bulk of circumferential dentin! And that’s on the mesial surface. Now you can bang down on that thing, and of course, you’re rotating clockwise now, so you could – if you did grab the head, you could tighten it up a little bit and drive it a little bit deeper. So, think about that counterclockwise idea. Here’s the staging platform. See how we come down there and just make a little platform, right in here, to put our ultrasonic tool.

So now you’re thinking ahead. Now I have circumferential space to put an instrument. And of course, I have radicular access, so I have a line of sight along the lateral surface, a corridor of vision, so I can see the tip of the file work. If I can’t see the tip of my instrument work, I said a file, but it’s an ultrasonic instrument, then, all bets are off. You can’t work blindly. You have to have direct vision. Back to the microscope, lighting and magnification is vision. If you wanna see it and do these things and become more successful at it, then you gotta visualize ‘em. So, we have a lot of drawings. We’ll clear the board. And there we are.

Now, what do you use? This is an endodontic instrument. It's a ProUltra, by Dentsply Sirona. Let’s not get carried away about the name brand. You want something that has the length to reach the field of activity. So you choose the instrument that is long enough to reach, and it’s narrow enough that you can see! You wanna have your lateral vision in here, okay? If you can’t see laterally, you might need a little bit more taper, if you have root bulk that can accommodate that. Okay. Sometimes, as you go deeper and deeper, the tool’s too big. So, you have to go to titanium. We talked about that in the earlier segment.

Titanium gives you longer lengths, narrower cross-sectional diameters, so you can reach. Now, they’re not as efficient. They don’t have the zirconium nitride sanding action of the instrument we just saw, the ProUltra 4, but you still can sand away. Well, sometimes as you go around and around counterclockwise, and you’re trephining, you can see this head moving around, but it has shape memory. It’s NiTi. Probably, the first generation or two of instruments, they weren’t heat treated. So, they were much stiffer NiTi. They had shape memory. That means they were manufactured straight, wanted to be straight, always tried to get [with emphasis] straight. That means this instrument wants to lay just like that.

So the head of it's gonna go into space. You can keep trephining, all day long. You can get clear out to there. The instrument’s just gonna end up over in here! So, then maybe you’ll do surgery and take it out the side! No, I’m just kidding. If you believe that, you’ll believe anything I tell you! So, back to the assignment at hand. Be aware that as you’re vibrating, it’s frozen there, and this is moving back and forth. You could break the instrument. So, you can actually trephine too long and presumably during the – due to heat build-up. So, the byproduct of ultrasonic trephining procedure is heat.

So, as you work along, temperature and time and temp, you’re gonna start going from 37 degrees, and you’re gonna build up. Now the build-up isn’t dangerous to the PDL, not at all. They’ve put thermocouples out here on roots, and they’ve measured trans dentinal temperature from ultrasonic trephining procedure. It’s about a degree! So, please, don’t worry about it! But I’m just saying, it’s always gonna go from shape memory to the outer wall. It’s axiomatic. NiTi will always end on the outer wall. Fine! There’s many other ideas we could begin to think about, but I wanna throw in another trick.

And I learned this trick many, many years ago, and I’d like to acknowledge him. His name is Dr. Stephen Niemczyk. He’s from the greater Philadelphia area. And he was helping me teach at the San Diego – I’m sorry, at the Scottsdale Center for Dentistry. So, many years ago, I was the Chairman down here, and I had a faculty, and he was on my faculty, and he was a fabulous [with emphasis] clinician, big thinker. And he told the group – so, I was learning from Steve. He said, “Why don’t you consider using some 17 percent EDTA?” Ethylenediaminetetraacetic acid, right? It’s a chelator! And we have a lot of debris packed in these flutes! And then, there’s debris packed between the wall and the file itself!

So, why don’t we consider a little trick! And I learned this probably 15 years ago, maybe 20 now, maybe 20 now. But why don’t we just consider taking a bead of aqueous EDTA on an explorer. So, put some EDTA in a Dappen dish. You can pick up a – you could use a 29-gauge needle. So, you could also use a 29-gauge, from UltraDent, and you could just – and – out of the field. Just squeeze the plunger, till you see a little bead. So, you’d see – here’s your cannula. And when you – whoop! When you have a cannula, and you squirt a little bit of material, you’ll have just a little bead. You can touch that bead right on the orifice, and it’ll run right down the canal. And as you’re vibrating, you come back, that vibration moves that EDTA deeper into the canal, it starts to remove the smear layer, and it frequently helps instruments jump up and out of the canal.

So it’s a really potent little adjunct that I wanted to show. And then, obviously you have a little transformational work to do in here, because from the staging platform you might’ve had a little irregularity. So, you work your instruments past that, and then, you blend this deep shape back up into the body of the canal. And you have a canal that’s basically the same kinda shape it would’ve been if there were no broken instrument. Okay. So, we have over here – I’m tryin’ to get you interested. We’re just about done. So, you see in an animation the step-by-step way which we look at how to do the technique, things that we’re thinking about with our radiology exam, the equipment, the ultrasonics.

The Stropko is critical [with emphasis] to blow dust out, to have continuous vision! So, as you’re working [makes burring noise], the byproduct is dust, and you blow that dust out. You work dry, so you can blow dust out, and it doesn’t become sludge and mud and obscure your vision. So, that’s some of the ideas. So let’s take it to here. And we’ll get a good look at this tooth. Now, I think we’d all agree, we probably see something right here, already. We might even think that’s a lesion of endodontic origin. The tooth has been opened. You can see an instrument’s broken, not only to the foramen, but slightly through, to and through. We don’t have big bulk of tooth structure, do we?

In fact, if I clear the board and give you a little better shot up in there, you can see a little line, right in here, and you can see a little line, right over here. Well, that is your furcal side concavity, okay? You’re looking right into the furca, and you’re seein’ this edge, and you’re seein’ that edge. The more you can throw those edges apart, in progressively, mesially angulated films, the greater the invagination! The greater the invagination. So, we’re gonna have to move this – you see a little triangle, got a horn goin’ up that way, got a canal goin’ that way. Here’s our long triangle. Clear the board!

Now, can you see the long triangle? We gotta get the – look at all this bulk! Look at how much bulk we have here and look at how thin it is over here. We gotta move this canal out and out and out. Look. If you wanna get out broken instruments, you need technology. But somebody can go out and buy technology, and they don’t know anything. So you gotta have what? Oh, training. Forgot about training. Gee, training! Yes, training. So, you need technology and training. Well, are you gonna be awesome on your first challenge? How about experience? You can’t teach it. You gotta earn it. Gotta earn it, the old-fashioned way!

So, if you have training and technology and experience, you can get a lot of these out. And master clinicians, I’ve known so many of them around the world, they look at these films, and they immediately begin to plan what they’re gonna do, how they’re gonna do it, what needs to be done. And I get the little hand there, good. And you begin to plan, “Can I get direct contact, visually, to the head of that file, no matter if it’s layin’ around the curve?” I like to use ultrasonics. This is from Dentsply Sirona, it doesn’t really matter. I’m just using a little ball, and I’m draggin’ it between the MB and the ML, that little interconnector. In that isthmus, we’ll frequently find a mid-mesial. So, I’m ruling that out.

And if it’s been ruled out, just like we’ve said, 4, 3, 2, we can start using our Gates Gliddens. We can use ‘em in a brushing motion, to flare. And then, we can use a staging platform, and now we see all that dust. So what do we need that we just learned? [Makes sh-, sh-, sh sounds] We need the Stropko! And what we do is, we’ll put a 29-gauge needle on the end. Notice how this luer locks up into the Stropko. This is the Stropko itself. So, you – industry makes many different cannula that can be inserted and threaded on, so when you push down on the air valve, you don’t blow this thing off like a bazooka! And literally, it’ll go across the operatory. So, you don’t wanna put out an eye.

So, luer-lock it on [makes sh-, sh-, sh sounds], blow that out, and here we go. Next slide, we can go right on and see exactly what we need to see. So when you can see it, don’t you have confidence? Aren’t you feeling like, “Wow! I’m learning something! I’m doing something I’ve maybe never done before”? And if you’ve done this a lot, you’re probably learning a couple little ideas that maybe you didn’t know about! So, there’s our circumferential staging platform. You can see the head of the broken instrument. You can see its cross-section. How about that? And there’s the staging platform that made that.

Well now I can set my pre-selected ultrasonic instrument, zirconium nitride coating, it’s a sander, so it’s pretty efficient, and I can start trephining counterclockwise, around the head. [Makes sh-, sh-,sh sounds] blow out that dust, continuous vision. The assistant’s got the high speed back! She’s got the Stropko! [Makes sh-, sh-, sh sounds] and it goes right up the hose! Ruddle has continuous chair-side vision. If you can see it, you can do it. So, you keep going around. You’d like to expose – remember? We can take broken instruments, and we can divide ‘em into thirds. If you can get about one third of the head of that broken instrument exposed, it’s yours, okay? So, that’s the goal. Try to get a third of it.

I gotta stop this, because I wanna show you somethin’. I don’t know if I can go back, but this instrument came outta here, jumped, hit the different axial walls, and went down another canal. Went down another canal. So, I said to the patient, “We have some good news, and we have some bad news. Which would you like first?” “Well, what’s the good news?” “Your instrument’s out. I got it out of the MB.” “What’s the bad news?” “It’s in the ML.” What I didn’t say to you is, always cover the other orifi with cotton pellets or some little blockage maneuver that you might come up with, CollaCote, because what you wanna do is prevent nuisance reentry into another canal.

Now, this happened, and I never even knew it happened. I’m being really honest with you. My multimedia guys called me and said, “Did you realize the instrument you got out went into another canal?” And I said, “No, I didn’t think that happened.” And they said, “Well, let me send you 30 frames a second, so you can watch 30 times in 1 single second the journey of that instrument.” So, it banged around internally, went into this canal. The assistant’s got the high speed, she’s got the – sshh! And she is using air [with emphasis], and it removed that instrument. If we looked at that again, you can see air removal is quite potent!

But in slow motion, 30 frames a second, you can see that instrument’s path into the exposed ML. The assistant’s blowing continuously. She doesn’t even know it’s happened. But just by blowing, you can see this thing start to unwind [drawn out], it’s comin’! I’m teaching air removal! Okay? Added value! Anyway, it pops out, you move on. We have a open, patent canal, because the instrument was occupying the apical third, the fragment. Little wiggle here on the 20, we can get past the impediment, the staging platform, and take it to length. Easily can go to length, because you can see there’s already a file that was to and through the foramen, so obviously, this one seats quite nicely.

And then, let’s look at the final result. You know, the furcal canal was there for a reason, and that’s because there was a lesion of endodontic origin, and the disease flow was along the anatomical pathways. And lesions form adjacent to portals of exit! So, it’s not a big surprise for Ruddle to see that we have a rope of material leaving the root and coming out towards the furca. And it has quite a bit of linearity! There’s quite a little bit of distance from that back canal, out to the cavosurface. Notice we kept our shapes quite conservative. They’re appropriate for the roots that hold them. Little bit of anatomy in the distal, but it’s pretty fun when we can provisionalize teeth, send them back to the patients – back to the dentist that they came from, and just have ‘em go ahead with the restorative effort. Everybody wins. The general dentist is happy, you know?

You know what they say about this? Well, when you break an instrument, you could say, “Your ass is on the line.” So, it’s really good to have a plan, to have some training, to have the technology, and have a little bit of experience. But when it gets a little bit more than you want, be sure to think about referrals, because referrals can help keep your practice ever rolling forward, so you can be more than you are, and you can optimize the care you give your patients. [Music playing]

CLOSE: What Does Phyllis Think?

Lisette

So, we’re gonna close our show today with the return of our popular segment, “What Phyllis Thinks”. And a lot of these questions are going to kinda reflect the world we live in today, meaning a pandemic. So some of the questions will be around that. But – so, here we go. Are you ready?

Phyllis

I’m ready.

Lisette

Thanks for joining us again, to give us your opinions.

Phyllis

Thank you. I finally had something to think.

Lisette

[laughs] So, the first question I have for you is, you are no longer eating out, due to the coronavirus pandemic. So how has it been for you to cook dinner – cook all the meals now, for several months?

Phyllis

Well –

Cliff

Did you want me to answer that, or her? Oh.

Lisette

[laughs]

Phyllis

-- for [laughs] four months. It’s something I had no idea when – going into this, I never thought – oh. I just assumed we would get take-out and relax and – but it was better to eat the food made at home. So, I had to change my thinking, and I now have lots of recipes and have been keeping us well fed, healthy.

Lisette

Have you gotten a little bit creative?

Phyllis

I have. We’ve found some new soup recipes, which –

Cliff

Oh, yeah.

Phyllis

-- we love. I dug out all my old cookbooks. I went through all my old Mom recipes and Gramma recipes and all my stuff. And so, yes, we’ve eaten very well and very healthy. Haven’t bought any junk food, at all, for like four or five months.

Lisette

I – that’s one – I’ve actually bought some junk food on Amazon, some Reese’s [laughs] peanut butter cups, because I --

Phyllis

[laughs]

Lisette

-- wasn’t going to the store that much to get that kinda stuff. You know, when you see it, you buy it.

Phyllis

I know.

Lisette

So what do you think is Dad’s favorite meal that you like – that you like to cook?

Phyllis

I think his favorite is tacos or mashed potatoes.

Lisette

Is that true?

Cliff

No.

Lisette

No [laughs]?

Phyllis

No?

Cliff

No, it’s true [laughs]. No, I like tacos. I could have ‘em every night.

Phyllis

Every night.

Lisette

That is my favorite, too.

Cliff

Because they have all these things in ‘em, so it’s like very varied.

Phyllis

And they’re not very hard. [laughs]

Lisette

[laughs] So, maybe you’ve also been catching up on some TV series or something on Netflix or Amazon Prime? Like what TV series do you think is definitely worth watching, right now?

Phyllis

My current favorite is “Yellowstone”. And it stars Kevin Costner, and it’s a ranch family, in Montana.

Lisette

And it’s a series?

Phyllis

It’s a series. It’s in its third season, I think.

Lisette

Is it on just regular TV?

Phyllis

It’s on a channel called “Paramount”, which I’m not sure what that is. I just set the recording, and it finds it. So -- and they were able to have a new season. That’s why it’s my favorite. It’s the only one.

Lisette

What is kinda the plot?

Phyllis

It’s sort of based on that ranch family that had problems with the government coming in and trying to enforce – I don’t know what they were enforcing, taxes or something. So, it’s kind of a rogue ranch family. It’s been in the – in their family for six generations. And they are getting along with the Indian families around there, and then, there’s a casino thing, and there’s – so, it’s a family thing. It’s --

Lisette

Okay. So --

Phyllis

-- a little [crosstalk]

Lisette

-- like a drama? It’s like a drama, maybe?

Phyllis

-- it’s a drama, with horses and some violence. Yeah.

Lisette

[laughs] Okay. So, earlier in the show, we talked about music therapy. So what – do you think music is important, and can you tell us how – the role that music has played in your life?

Phyllis

I grew up with a lot of church music, which was my first, you know. And that was very strict. We didn’t get to listen to other music, but every time my dad was traveling and not at home, my mom would listen to the Grand Ole Opry. So, I grew up with a love for country music. To this day, everybody around me has to listen to country music. And I hum along, all the time, while I’m working.

Lisette

Yeah. I – I’m surprised. At work, at the office, listening to the country music all day long, and growing up listening to country music all the time – and I don’t listen to country music, unless I’m with you!

Cliff

Right.

Phyllis

[laughs]

Lisette

And – but it’s like – surprises me sometimes, like I – “Oh, my God! I know the lyrics to this song!” [laughs]

Phyllis

I know, I know.

Cliff

Well, people might not know this, Lisette, but she’s quite a guitar player. And when I was in grad school in Boston – she played for years before that, before grad school. But in Boston, she literally played her guitar every night, and I fell asleep in the beanbag.

Phyllis

[laughs]

Cliff

And my classmate, Fulton, he was doing the dishes [laughs]. Not so bad. Phyllis made dinner, Fulton did the dishes, and then, I fell asleep being serenaded by “Patches” and all these country songs.

Lisette

[laughs]

Phyllis

All the Joan Baez songs.

Lisette

Yes, we actually debated having you play a little song --

Phyllis

[laughs]

Lisette

-- on the guitar for us. Since we had Rik at the beginning, we thought, you know --

Phyllis

No, that would be scary.

Cliff

Oh!

Lisette

-- make it a whole musical show!

Phyllis

Very – yeah. I’d have to do a little practicing. [laughs]

Lisette

[laughs] Okay. So, what is one thing about quarantine life or social distancing that you have found that you actually like?

Phyllis

There’s more time to read. I’ve read about 10, 15 books during the last few months. And I got tired of TV after a while. There’s no new shows, really, nothing – you just get tired of it.

Lisette

No sports. But [laughs] --

Phyllis

No sports, no. Yeah. And that’s fine. But reading, just have it quiet, and reading. I have really enjoyed that.

Lisette

-- what would you say your favorite book that you’ve read in the last year that maybe you would recommend to others, and why?

Phyllis

One of my favorites of all time that I read, and it was recommended by a friend, it’s called The Nightingale. And it’s the story of the French Resistance, during World War II, when they invaded France.

Lisette

I think I’ve heard of it, actually.

Phyllis

Kristin Hannah is the author, and it was excellent [with emphasis], and it had insights that you’re thinking, “Oh, my God! They survived that!” And [crosstalk] --

Lisette

Is it kind of – is it all a true story, or is it embellished with --

Phyllis

-- it’s based on a true story.

Lisette

-- fiction?

Phyllis

Nightingales were the Resistance fighters that got the soldiers who were captured behind the lines or landed behind the lines, got them out of the country and back, so they could get back in the war and help fight some more. So, it wasn’t one person. The book is based on one person, named The Nightingale. But in reality, there – it was a group, and they called them The Nightingales, because everything was done at night, getting them out of the country, getting them back to England.

Lisette

Interesting.

Phyllis

Yeah. It’s an excellent book, really good.

Lisette

Is it, like, suspenseful, too?

Phyllis

Yes, because you’re not sure. The way they wrote it, you’re not sure exactly who’s alive at the end of the book. And it’s kind of a surprise and was a tearjerker.

Lisette

[laughs] Oh, gosh! Okay. And then, so, what would you say that – the one thing about quarantine life or social distancing that you really can’t stand, at all?

Phyllis

I didn’t realize this was going to feel like this, but I am so involved – I was [with emphasis] so involved in our travel, planning, coordinating. That was my social life!

Cliff

[laughs]

Phyllis

And I never thought about that, until it was suddenly –

Cliff

Little sad [laughs]?

Phyllis

-- yeah. It was suddenly gone. I’m not coordinating any flights, I’m not getting any hotels, I’m not communicating with meeting planners, and we’re not going to meetings. So, I’m not meeting any new friends or seeing any old friends. So that has been kind of a sobering thing.

Lisette

That’s weird, because I thought you were gonna say not seeing me, every day --

Cliff

[laughs]

Phyllis

[laughs]

Lisette

-- and seeing the grandkids every day [laughs]. But [laughs] --

Phyllis

Well, that’s true, too. Yeah. But at least I know you’re here.

Lisette

-- [laughs] okay. So, now, to everyone who knows you, we all know that you wear many hats. She’s a computer programmer, hair cutter, office manager. What else? Accountant, and then, wife, mom, gramma. So, if you could start all over, what would be your career of choice?

Phyllis

My career in high school, my career of choice was to be a hairdresser. And it says that under the picture in the yearbook, and it’s the worst hairdo you have ever seen in your life!

Lisette

[laughs]

Phyllis

It’s quite hysterical. But as I – then, I went into computer programming, which I loved [with emphasis]. But my long-term goal, I always wanted to be a surgical nurse and help do surgeries in hospitals. I actually had that on a Post-It on the mirror, for a long time, that I was gonna go back to school and become a nurse.

Lisette

Well, they need nurses, now. So [laughs] --

Phyllis

I know. I know. I think, right now, there’d be too much – a little too much school for me to go back and do that.

Cliff

Phyllis has an inventor gene in her, I don’t think anybody knew about, but -- I think this was 40 years ago. We read some story in the paper that some person had an exacerbation following surgery, and they had to go back in, and they found a sponge. You know what she said?

Phyllis

[inaudible]

Cliff

“They should have bar codes on those sponges, so they can just scan the belly, before they close, and it would pick it up.’” And I’m going, “That actually happened, like 20 years later. And now, it’s routine.”

Lisette

-- wow!

Phyllis

Should’ve gotten the patents, along the way [laughs].

Lisette

Okay. So --

Cliff

Oh, the old inventor. [laughs]

Lisette

-- the last question I have for you is just related to your personality. You always are so calm. Even when there is like some upset, you are by far the calmest of everyone in how you deal with things. So, what would you say are three words or phrases that best describe your personality or outlook on life? And how have these – and that these qualities – how have they helped you, basically?

Phyllis

Number one, a sense of humor. I find something funny about everything. And I find that that really helps other people relax. If you can get ‘em to smile, or you see that it clicks, that they see the funny side of it, that is – for me is number one, is a sense of humor. And then, I’m very realistic. And I’ve always been like that, since about 19 years. And I had kind of a tough childhood, with the strict religion thing, that I had to sort things out and come to a certain amount of realistic belief on my own. So, I’m very realistic about things. And the third thing is, I’m a studier of history. I love how history repeats and human behavior and the pendulum swings. So I’m a strong believer in whatever – if it’s really bad today, it’s gonna be really good tomorrow. History repeating.

Lisette

Well, thanks, Mom. I mean, if anyone knows our family, she is like the one that keeps us all grounded and, like – it’s like she definitely is the matriarch of the family and not just because [laughs] you’re the gramma. But I mean, you definitely are like the person on the ground, holding the kite, and we’re all flyin’ around.

Phyllis

[laughs]

Lisette

So, you keep us from all flying away. So, thanks for coming back and joining us on the show. Thanks, Dad. Thanks, Mom. See you next time on The Ruddle Show.

END

Watch Season 4

55:16

s04 e01

Tough Questions & SINE Tips

Who Pays for Treatment if it Fails and Access Refinement

54:02

s04 e02

Endodontic Diagnosis

Assessing Case Difficulty & Clinical Findings

50:12

s04 e03

CBCT & Incorporating New Technology

Zoom with Prof. Shanon Patel and Q&A

56:53

s04 e04

Best Sealer & Best Dental Team

Kerr Pulp Canal Sealer EWT & Hiring Staff

49:44

s04 e05

Ideation & The COVID Era

Zoom with Dr. Gary Glassman and Post-Interview Discussion

59:00

s04 e06

Medications and Silver Points

Dental Medications Q&A and How to Remove Silver Points

53:40

s04 e07

Tough Questions & Choices

The Appropriate Canal Shape & Treatment Options

53:15

s04 e08

Q&A and Recently Published Articles

Glide Path/Working Length and 2 Endo Articles

46:19

s04 e09

Hot Topic with Dr. Gordon Christensen

Dr. Christensen Presents the Latest in Glass Ionomers

00:52

The Ruddle Show

Commercial Intro S04

01:43

The Ruddle Show

Commercial Promo S04

Watch Season 3

48:42

s03 e01

Treatment Rationale & Letters of Recommendation

Review of Why Pulps Break Down & Getting a Helpful LOR

52:27

s03 e02

Profiles in Dentistry & Gutta Percha Removal

A Closer Look at Dr. Rik van Mill & How to Remove Gutta Percha

48:10

s03 e03

Artificial Intelligence & Endo Questions

AI in Dentistry and Some Trending Questions

58:54

s03 e04

How to Stay Safe & Where to Live

A New Microscope Shield & Choosing a Dental School/Practice Location

48:20

s03 e05

3D Disinfection

Laser Disinfection and Ruddle Q&A

48:28

s03 e06

Andreasen Tribute & Krakow Study

Endodontic Trauma Case Studies & the Cost of Rescheduling

55:22

s03 e07

Ruddle Projects & Diagnostic Imaging

What Ruddle Is Working On & Interpreting Radiographs

1:05:24

s03 e08

Obturation & Recently Published Article

Carrier-Based Obturation & John West Article

55:48

s03 e09

Retreatment Fees & the FRS

How to Assess the Retreatment Fee & the File Removal System

1:00:42

s03 e10

Research Methodology and Q&A

Important Research Considerations and ProTaper Q&A

00:44

The Ruddle Show

Commercial Opener S03

01:05

The Ruddle Show

Commercial Promo S03

Watch Season 2

51:43

s02 e01

ENDO 101: WAVEONE GOLD

Product History, Description & Technique

51:42

s02 e02

Interview with Dr. Terry Pannkuk

Dr. Pannkuk Discusses Trends in Endodontic Education

58:21

s02 e03

3D Disinfection

GentleWave Update and Intracanal Reagents

1:04:53

s02 e04

GPM & Local Dental Reps

Glide Path Management & Best Utilizing Dental Reps

1:01:10

s02 e05

3D Disinfection & Fresh Perspective on MIE

Ultrasonic vs. Sonic Disinfection Methods and MIE Insight

53:03

s02 e06

The ProTaper Story - Part 1

ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos

57:53

s02 e07

The ProTaper Story - Part 2

ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos

1:06:40

s02 e08

Interview with Dr. Cherilyn Sheets

Getting to Know this Top Clinician, Educator & Researcher

1:13:21

s02 e09

Broken Instrument Removal

Why Files Break & the Ultrasonic Removal Option

49:01

s02 e10

3D Obturation & Technique Tips

Warm Vertical Condensation Technique & Some Helpful Pointers

Special Reports

36:27

special e02

SPECIAL REPORT: COVID-19

The Way Forward

51:17

special e01

SPECIAL REPORT: COVID-19

How the International Dental Community Is Handling the Pandemic

Watch Season 1

45:30

s01 e01

An Interview with Cliff Ruddle

The Journey to Becoming “Cliff”

52:35

s01 e02

Microcracks & the Inventor's Journey

Ruddle Insights into Two Key Topics

47:17

s01 e03

Around the World Perspective

GentleWave Controversy & China Lecture Tour

40:29

s01 e04

Endodontic Access

What is the Appropriate Access Size?

52:13

s01 e05

Locating Canals & Ledge Insight

Tips for Finding Canals & the Difference Between a Ledge and an Apical Seat

53:14

s01 e06

Censorship in Dentistry

Censorship in Dentistry and Overcooked Files

50:22

s01 e07

Endodontic Diagnosis & The Implant Option

Vital Pulp Testing & Choosing Between an Implant or Root Canal

55:30

s01 e08

Emergency Scenario & Single Cone Obturation

Assessing an Emergency & Single Cone Obturation with BC Sealer

49:36

s01 e09

Quackwatch & Pot of Gold

Managing the Misguided Patient & Understanding the Business of Endo

58:05

s01 e10

Stress Management

Interview with Motivational Speaker & Life Coach, Jesse Brisendine

Continue Watching

01:52

Behind-the-Scenes Studio Construction

Timelapse

01:53

Happy New Year

2020

01:05

The Ruddle Show

Commercial Promo S02

00:44

The Ruddle Show

Commercial Opener S02

00:56

The Ruddle Show

Commercial Opener S01

Disclaimer

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.