Dentistry, Philosophy & Merging Systems

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…Logic. So, that's the study of correct reasoning and argumentation. Now, is logic ever used in dentistry?

I rarely could grasp it…

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

How are you doing today?

I'm doing pretty good. What about you?

Excellent. And how are you doing today out there? I hope everybody's great. We have a great show.

All right. Well, we wanted to start off today talking about the Emblem of Dentistry, which is here behind us and it has been in use since 1940 and was adopted by the ADA in 1965. But even if you are a dental professional, you might not understand all of the emblem symbolism. So, when I first brought it to you, you weren't aware of this, right? Of the symbolism that was in it?

No, I was aware of the emblem, and the emblem always scared me because it had a snake.

Yeah, it's also very similar to the one in medicine.

That's why I became a dentist, because the medicine had two.

All right. Well, they're both inspired by Greek mythology, and they both feature a snake coiled around the rod of Asclepius, who was the son of the Greek God Apollo. So, Asclepius was the god of medicine and healing, and he could also transform into a snake. So, that is why the staff and the snake. Now, I know you really don't like snakes, right?

No, I'm not too fond of snakes. You'd have to say that's true. That's why the emblems were never that important.

And at the end of our show today, we will actually have the origin story of your snake phobia. So, we will actually return to that in a Ruddle flashback at the end of the show.

Notice how they're making me revisit an uncomfortable area of my life.

Okay. Well, snakes are the symbol of rebirth because they shed their skin. So that's, you know, why it's important. Okay. So, why don't you tell us though about the triangle and the circle?

Well, yeah, good, you pointed out that they are shapes, mathematical shapes, but actually they're Greek letter alphabet. That's how they are. So, D for delta, the triangle, the delta, that's for dentistry. The O that's intertwined in all this emblem is for O-dont, and that's the Greek letter O for O-dont or tooth.

[crosstalk]

So, that's the two big pieces. And then, there's all those leaves, and maybe you noticed them, or maybe I never noticed them, really. I knew something was there, and berries. The leaves, there are 32. And that rings a bell if you're a dentist, there's 32 permanent teeth. I like how they call them permanent, like they're always there. Anyway, the berries, there's only 20 of the berries and that would represent each of the primary teeth.

All right. Well, that's kind of clever. These are, by the way, the recommended or suggested colors, the purple, gold, black, and white. And importantly, the purple color or lilac is the official academic color of dentistry.

Uh huh. Well, it's a great logo. I mean, I have, I'm looking at right here in color and you can tell I carry it constantly with me. We also have a logo, I don't know if people ever talk about that. They just look at that little thing we have on our artwork, it's an emblem. It does have some symbolism. So, everybody saw the triangle, it's really a tetrahedral, it's a four-faced triangle, if you will, in three dimensions, and every face is symbolic of—I have different ways I look at it, but in our family we look at as education, community, innovation, and lifestyle.

Yes. And we do have that logo and everything about our logo on our website in the About Section. Maybe we'll also put it into show notes because it's kind of interesting. Like, a lot of times you see a logo or an emblem, symbol, whatever, and you know immediately what it stands for or what it represents. But oftentimes you don't know that each element actually has a lot deeper meaning and when you actually learn what that is, sometimes you appreciate the logo a lot more.

So, we have a great show today. It's going to be a very meaningful one. So, let's get to it.

Okay. So, probably a lot of you have heard a child say maybe even your own child at some point say something along the lines of I don't understand why I have to study history in school because I plan to be an auto mechanic. Or maybe even you, yourself, as a college student, were wondering why you had to take all these general requirements that seem to have nothing to do with what you actually wanted to do for your career.

So, last season, we introduced a segment called Intersections, and it's where we explore the overlap between dentistry and another field in education. So, last season, we did a little mini segment called Intersections Math and Dentistry. And we actually were quite surprised to find out that math was used a lot more in dentistry than we initially suspected.

Yeah.

So, that—and check out that opener if you're interested. This time, since we had so much fun doing that, we're doing a little longer segment this time, and it's gonna be the intersection between philosophy and dentistry. Now, at first glance, these might seem like two pretty different fields of education, right?

I would agree with that. Philosophy would be, for me, much more abstract. And philosophy is the study and the systematic analysis of questions and issues and aiming to resolve the world and the world we live in. Whereas dentistry is mainly using fundamental knowledge and once you have a narrow field of knowledge in dentistry, oral health, then it's the execution through methods, concepts, techniques, technology. So, you can measure all your steps, you can see things, so it seems more black and white.

Right, but there's still like, different philosophies of treatment, right, that people use that phrase?

Yeah. So, where we probably start to realize that all dentists have interface with philosophy in their work is we see these sentences, paragraphs. You know, I was just with Phyllis and she was having some medical stuff and then we were getting our physicals after 50,000 years and we saw all the mission statements in the magazines.

So, probably dentists are familiar with that and do work it into their websites, their mission statements. Community, you know, community dentistry, some of them are talking about how they would relate to the community and be available and help grow things through word of mouth and patient satisfaction. They also have things like patient-centered, so we see a lot of, you know, take care of you, the warm towels and, you know, all the stuff where we look at their desires and their wants versus their needs and trying to make it all fit.

Conservative treatment, we've always said we want the teeth to last as long as each patient. So, there's a great emphasis in conservative treatment as to have a good foundation, keep the teeth there as long as possible and aesthetically pleasing.

And then, of course technology. A lot of people like to put on their websites that they have this, that, and the other. And I think some patients look at that and go, oh, they're up to date. So, there are some philosophical statements in dentistry.

Yeah, it definitely seems like there's a focus your practice might take. Like you said, patient, community, technology, that kind of thing. And you did mention that most websites today will have some type of mission statement or philosophy of care statement, and just a few sentences about what you can expect there as a patient, maybe just stating their commitment to excellence, that kind of thing.

So, philosophy is a pretty broad subject. I mean, there's a lot of different branches of philosophy, so we'll go through a few of them and then we'll see how they relate to dentistry. So, the first one we're gonna look at is epistemology, which is the study of knowledge and how you know what you know. So, how does this relate to dentistry?

Well, how you know what you know probably reminds you of an old expression, who you are is where you were when. I'll take this out to the ridiculous, but even the country you were born in will probably influence to some extent your philosophy on all of life, including dentistry. Maybe you went to church and there was a religion that your family participated in, that's gonna affect it. Were your parents college-educated? Did they, are they working in vocations? It's all good, but socioeconomic level.

And then, of course there's preschool, kindergarten, grade school, high school, college, and then we get to dentistry and the field. I think at University of the Pacific in San Francisco, it was Art Dugoni for me. Now we're talking about people that might have influenced you heavily. So, I never took classes from Art. He was an orthodontist, but he was a leader. So, your mentors would have helped you a lot. You might have fallen in love with how they talk or what they could do with their hands or how smart they could look into treatment plan and they could see things.

So, all those serve to influence how we approach our work.

Yeah, I've heard you say before, if you name an endodontist for me and you tell me where they went to school and who their mentors are, I probably already have a pretty good idea of maybe what techniques or technologies they prefer and how they practice. So, I mean, I've heard you say that before.

You're from a lateral condensation school.

All right. Well, let's move on now to another branch of philosophy, logic. So that's the study of correct reasoning and argumentation. Now, is logic ever used in dentistry?

I rarely can grasp it, but no, logic is used every single day. Just think of diagnostics. Somebody comes in with a toothache. Well, there's a whole logical way you ask questions, be a great listener, and then once you have the information, there's usually a pathway. You know, you're gonna do percussion first, you're gonna do a cold test, you're gonna do a hot test. I mean, there's all these tests that we do, and they're not always all indicated, but we're trying to have enough information to make a diagnosis.

You mentioned this and I liked it, order of treatment. Well, you don't fill until you've cleaned and you don't clean until you've shaped. Okay? You don't put the crown and cut the margins and put the casting on before you initiate treatment five minutes later because you'll have a hole through the brand new crown.

So, even in medicines, pharmacology, when your people come in, you got to question them and listen to their medical and their dental, and then of course you think about, oh, I'm going to be giving this anesthetic, oh, I probably will have to prescribe this medication, maybe even this one, and you got to know how that relates to the medications that they are already on.

Yeah, you mentioned like just really like you shape before you clean, before you irrigate and that just seems very obvious, but sometimes like, if you're seeing a patient and they require a lot of different things done and maybe it's very multidisciplinary that's going to have to happen, it might not be so obvious. You might actually have to really think about it a lot more, like what should come first. So, sometimes the logic's really obvious.

I forgot that one. She's talking about sequencing treatment.

Yeah. So, I mean, you mentioned a proper sequence just, you know, as you're treating a patient, but also it might even be a little more complex, so you might actually really have to think about which logically we should do first. I think it's not so obvious.

I think you put the implant in first and then you do the bone augmentation around the implant or do you build a ridge up first and have a good site for the implant? Yeah, we use a lot of logic.

All right. I think we actually probably use logic in a lot of areas of life, in a lot of different areas of education.

We hope we do.

Yes.

We hope.

All right. Well, let's now move on to another branch of philosophy, and this is ethics. Now, I know ethics is used a lot in dentistry because we're talking about it all the time, it seems like, on our show and on the podcast. That's the study of moral principles and values. Now, obviously, dentistry has a standard of care and is guided by the Hippocratic Oath, do no harm while trying to improve the patient's health, something like that. But what other areas of dentistry does ethics affect?

Well, I think you wrote and gave me a suggestion here, just and fair treatment. I don't care who you're treating or who you're seeing, if you decide to treat anything, I'm going to be doing the Cliff Ruddle job. That's the job I know to do. I don't know how to do a lousy job. I have done lousy jobs, but I'm not intentionally trying to do a lousy job.

So, I think everybody, whether it's the famous person, the influencer, the surgeon, the janitor, they all get 100% of Ruddle. I would say probably the most important things with ethics is to really powerfully communicate to your patients all the treatment options. You know, it's a tooth that needs a root canal, but you must tell them about the root canal and how long it might take to do it, the chair time and fee for that particular tooth, and the follow-up treatment that might be required.

As an example, you might say, I want to tell them to get it extracted. Okay. We've got to tell them about the extraction, so low fee, get the tooth out. But now we have a space, theoretically, if there's a posterior tooth, and we could have tipping. We could have occlusal problems. So, you have to tell them all the various treatment plans, all the various options, the time and the cost associated with each one and help them, you know, if they need help, they'll probably know what they want to do, but guide them towards that.

And one of my pet peeves is somebody broke a tooth off and there's a wedding tomorrow. You're not doing full mouth treatment planning. They want the tooth there for the smile tomorrow morning. So, you can talk to them in general about oral health and the highway there, but I think we got to tell them along the way we do things to get them, you know, happy and confident and then they'll be more likely to come back and follow the treatment plan.

Yeah. And importantly, I think you also have a duty to report any errors you make during treatment. That would be, I think, included. I thought it was interesting when we did that podcast where we looked very closely at the standard of care for endodontics, that it was a lot mostly about like respect, confidentiality, just and fair treatment, but not so much about you need to use a certain type of technology. So, I think technology is kind of a little bit separate from just the ethics and standard of care in dentistry.

One thing our audience will relate to being a fair and just treatment, somebody could come in with any socio economic level, we can put them at the bottom, put them at the top, put them in the middle, anywhere along the way, and they come with a roaring toothache. You don't have to do the whole root canal treatment. Palliative treatment. Get them out of pain. Now, we can talk to them and they're listening, they're hearing what we say better because, you know, they're now comfortable and they probably have some confidence in what happened. So, it's treating people like you'd want to be treated.

Okay. Now, let's move on to another branch of philosophy and that's aesthetics, which is the study of beauty and art.

Anesthetics or aesthetics?

Aesthetics. And I mean, I've even seen titles of textbooks and stuff, the Art of Endodontics or something like that. So, I mean, now, and of course there's aesthetic dentistry because we all want to have beautiful smiles. But when you study aesthetics and philosophy, it's actually important to study the two concepts that work together, form and function. So, it's not just about beauty, it's also about being functional as well. So, maybe tell us how this relates to dentistry.

Well, I guess I can say it this way. So, I was a member of the American Academy of Aesthetic Dentistry. It's an elite group in North America. There's 100 members by invitation only. And I was a member for several years. And you know, you hear the word aesthetic dentistry, AAED, aesthetic dentistry. And of course, they all showed cases after reconstruction and beautiful smiles, and you think about that.

But I want to point out something that is dear to my heart, because when I spoke to the Academy of Aesthetic Dentistry, nobody can see our work. It's all below the bone; you need an x-ray. So, I made a big joke about this when I'd speak to them, and really the joke was on all of us. Because when they're doing these crown preps, you can do lousy crown preps, or you can do very mechanically oriented crown preps with great retention, the cements, the materials you're using.

Are you gonna use a porcelain fused to metal crown? Are you gonna use some other kind of a silicate or resin type casting?

There's many differences, aesthetic differences, but we can have aesthetic dentistry and great smiles, but in endodontics, we want like, you look at a root canal. Has it got symmetry? Is it flowing smoothly and going with the curvatures of the roots? Is it look like it's anatomical? Was there some effort to 3D disinfect because we can see evidence of lateral canals, portals of exit filled, where files never touch, and then what was the obturation technique to fill all that? So, there's a whole bunch of things that I think are very aesthetic, but they're never seen by the patient.

Yeah. No, just a couple examples I can think of when we—well, you talk about the smooth flowing preparations and how they're kind of conical sort of.

Oh, they grace and flow within the roots that hold them.

Right. But there's a reason why they are tapered, you know, to hold the gutta percha, like it's functional.

Bingo. So, we don't just—her point would be just based on the presenting anatomy, we're trying to get some kind of a conical shape, a Schilder objective would be fine. Because to her point, if you have deep shape, and we've talked about that a lot, it's going to hold our reagents and we'll have less accidents. That means happier patients. To her point, you can push on that thermal softened cushion of rubber and drive out hydraulically all the materials into the anatomy. You can do that when you're like this. But if you're parallel, or you have reverse architecture and you push, it goes everywhere. So, yeah, aesthetics is funny. You said form and function, perfect.

Yeah. And just even thinking about that podcast we recently did where people were getting full arch implants so their teeth might look nice, but then the occlusion was all off and they couldn't chew properly. So, yeah, so both of those things need to work together.

Looks good; can't use it.

Right. All right. Well, we've talked about now epistemology, aesthetics, ethics, logic, and they all play a pretty big role in dentistry, but what about philosophy of the mind? So, that's the study of the play that happens between the unconscious and the conscious, like how your belief systems, your feelings, your intentions, your self-talk affect actually your performance and actions. So, to better understand—because I actually, I imagine that when you're working on a patient for a long period of time, there's probably a whole internal conversation that's happening while you're working.

Oh, yeah.

So, to better understand this idea, we actually called on a leading philosopher endodontist we know, Dr. John West, to give a more thorough explanation.

Oh, John David West, JDW, always a big smile on my face when I speak that name. John has a way of bringing endodontics like most teachers can, but there's this other dimension of his teaching that I so admire. I would say Tony Robbins has it. He's asked by Fortune 500 companies to come out and give a talk because the whole crew, which could be 10,000 employees, they're a little flat today. So, John is able, as he'll tell you, he's wiring into more of those billions of neurons than I think a lot of us, and he sees things in a way that's different. And we should just hear from John and see what he has to say.

Yeah. Let's hear what John has to say about the connection between the philosophy of the mind and dentistry.

[West Video Begins]

Hello, everyone. I'm John West. Cliff Ruddle and Lisette have invited me to participate in this Intersections segment of the Ruddle Show. A previous intersection was between math and dentistry. This intersection is between mind and endodontics. I've entitled my short soliloquy, “Conquering the Endodontic Mind”.

Now, before I give you the secret of conquering the endodontic mind, I want to give you the backstory. So, we've been told that love is the greatest gift that we've been given, and I can't dispute that. But I would say the second greatest gift that we've been given is choice. Choice of the mind. And that's my subject today. I'm gonna read you a few quotes. I think you've heard them before, maybe many times, but you haven't really heard them, but the relationship of the power of the mind and choice.

“What we think we become,” Buddha.

“As a man thinketh, he becometh,” Proverbs.

Shakespeare's Hamlet, “Things are not good or bad, but thinking makes it so.”

Henry Ford, “Whether you think you can or whether you think you can't. You're right.”

Napoleon Hill, “Whatever the mind can conceive and believe, it can achieve.”

Deepak Chopra, “You are not what you think you are, but what you think you are.”

And Einstein himself said that, “We cannot solve our problems with the same thinking that we created them. We must think differently.”

And even the little red engine, remember the little red engine? “I think I can, I think I can.” And if you think you can, you can. If you think you can, you can.

Well, these are powerful quotes, but you know what? Sometimes they don't work. They don't allow us to reach the end of the canal. They don't allow us to create the practice of our dreams. They don't allow us to get a future memory into the present. And so in order to do this, we need to tap into our brain. We have 100 billion neurons in our brain, at least I used to. And what is the purpose of those neurons? The purpose of the neurons are to keep us alive until tomorrow. Homeostasis. They really have very little to do and they're sitting there desiring to be cultivated to do something like reach the end of the canal or create that practice of your dreams.

So, this is called quantum mechanics or quantum physics, and I'll give you an example. Last week, I was at IDEA, Interdisciplinary Dental Education Academy in the Bay Area, for four days with my son Jordan, and then separately two days at Gordon Christensen's practical clinical courses in Provo, Utah. And I tell them exactly how to make a glide path, tell them the four barriers that can prevent that and how to overcome them, and still they come to me almost immediately, I can't get down the canal.

And so, I always do the same thing. We hold the tooth in front of the microscope, they're looking at a monitor. And I'm saying to them, okay, imagine the file at the end of the root. Can you see the file at the end of the root? No, I'm trying to get there. No, but in your theater of your mind's eye, can you imagine the file two millimeters past the end of the root? Oh yeah, I can see that.

Okay. So, we want to incorporate the visualization engaging the mind that way. Then we have to incorporate the emotion, the feeling. Can you feel it in your gut now that you've reached the darn thing? Yeah, I mean, that feels good. I've been trying for half an hour. Yeah, I know. Okay. Now, keep that seeing and that feeling. And now what are you thinking about yourself? What's the belief system now that you've actually reached the end of the canal? Well, I'm pretty good. I guess I'm confident. I got that skill. Yes, you do.

Now, let's see it and feel it and think it for 10 seconds. We're gonna hold that thought and I'll tell you when the 10 seconds is up. [pause] Okay. Now, let's do it. And always we reach the end, but we have to do it, all the skills and bring that all in. But it starts with the see, feel and think.

So, I want to give you a practical idea of my own self. About a year and a half ago, I was noticing I was getting voids in some of the packs. And endodontists, we hate voids in the pack. Anybody can create a void. A schmuck can do a void, but a great endodontist has solid packs. So, what I didn't want to do was to have voids. So, I didn't want to make voids, but that's what I didn't want. What I wanted was to make solid packs.

And so, I wrote down, I make solid packs, and I pasted this on the wall where he pushed the button to take the x-ray, where the monitor was, where the patient's pre-treatment film is, in the bathroom, the toilet seat, above the toilet seat. I put it on the steering wheel at home, and multiple places. So, that what needs to happen to cultivate these neurons to think differently is they have to fire and wire multiple times. It's not a one-time thing, like change your mind, something like that.

And so, when I was at this last class, there was an endodontist who was breaking files. So, this is a great example. And I knew that it required a surgical and a savage intervention. And so, what I did is I introduced a rock and put it in his shoe so that every time he pushed on the rheostat, it hurt his foot and he made him think, ah, be gentle. Well, after a day and a half, he had a sore foot and he was also gentle and he wasn't breaking files.

So, this is what has to happen is you have to have that remember to remember to repeat, seeing the outcome you want, bringing the future into the present possession, not longing for it, feeling it in your gut. And then, thinking a new belief system, and holding that for 10 seconds as many times in the day as you can.

In conclusion, this is conquering the endodontic mind. It's a neuro transformational process and really what it is, is making your brain right by making it wrong. And we need to do this by remembering to remember. And if you can't remember with this class or this little presentation and you need a memory to remember, rock on.

[End West Video]

John, thank you so much. That was an awesome way to wire our brains to tap into more information so we can take the rock out of our shoe and proceed.

Yeah. I think it reminds me of what you quote you like to say by Henry Ford, “Whether you think you can or you think you can't. You're right.”

Yeah, that's a pretty good one, huh? Remember that one.

All right. Well, that is it for this segment. We can see that there's actually a pretty large intersection between philosophy and dentistry. We just have to remember that it's not always black and white. A lot of times there's many shades of gray in the middle. And actually, for me, I find that really exploring and understanding those shades of gray is sometimes even more rewarding than, you know, just studying the obvious.

I think when you're out there in the 50 million shades of gray between black and white, that's where there's a lot of knowledge that can be learned, understood, and practiced.

All right. Thank you.

It's good to see you and be with you at the board again. I'm gonna talk about a topic that I actually never really talked about on the road. So, in all the miles I've racked up over all the decades, this wasn't ever something I talked about at the board with you present. It was something that was maybe just as a sidebar in Santa Barbara seminars. And it's turned out that this is a topic of interest. I get asked questions about it, and we can get better in our endodontics if we just understand about systems.

In other words, if we're in the same route, the same fused route, do the systems merge or are they separate over their length? Now when I say separate, they might have anastomosis and communication like that, but do we have two orifices and two apical portals of exit? I call those 2-2. Or do we have two orifices and one apical portal of exit? 2-1.

So, how we approach our preparing the canal and all that is going to influence iatrogenics. It's going to influence cone-fitting, and it's going to influence hydraulics, packing, surplus after filling will be more dominant if we don't understand what we're doing, and it's led to extrusion of the materials and caused some problems in around sinuses, neurovascular bundle, and the mental foramen.

So, today we're going to talk about systems. It could be a mandibular molar, could be the MB and the ML, mandibular molar. It could be any systems in any tooth and mouth. They're the same root. The question is, are they 2-2 or are they 2-1 or is it 2-1-2? And there is infinite anatomical configurations. I just want to know where they are at the end of the route, separate or together.

Okay. So, there may be all kinds of Hess type anatomy in any route that we want to talk about, but let's figure this out. All right, we'll get started. Boy, this is a lot of fun, and I know you're going to love this lecture. Here we go.

So, we start to take our favorite tooth in the mouth, the biggest tooth by volume, the most misunderstood tooth, the tooth that has generated more research than any other tooth. It would be the maxillary first molar. And because it has that big MB root, that MB root is a root that is a little tricky for some of you because it's a little bit like this. So you have a bigger MB2 and then you might have an anastomosis and a groove off to a smaller MB1.

Okay. Notice what I'm trying to show you the distance across the buccal aspect of that route is much greater. We have a much bigger cross section. We can do a little bigger fuller shape. When we get to MB2s, we have to recognize they're in a smaller cross section. And because the cross section is smaller, we have to have a more conservative prep that's appropriate for the route that holds the canal.

That's the first thing I want to talk about. The cross sectional configuration of the MB route over length. For CBCT people, you're going to understand this quite well as you drag your mouse and you look at the different cross sections along the length of the route. For us that use 2D films, even multiple images, it's not as clear.

All right. So, if we just open the tooth up and you're looking down in, you'll typically identify your orifices. We're not talking about the zebra. We're not talking about a tooth where it's a block of dentin. You can't even find your first orifice. In this scenario of education today, you can find the orifices. There they are on the pulpal floor. Notice again, our MB1 is a little bigger typically, a little smaller in cross-section because it's appropriate. The tooth was, if you will, go back to embryology and stuff like that, the canals formed appropriately within the roots that hold them. So, you don't have huge canals and little, tiny roots, unless you're talking about a young tooth, an emerging tooth, a younger patient.

So, if we look at the orifices, immediately, you know, I know, I think we all know, the MB1's a little easier. That's the one we usually want to negotiate. So, we can't see all this. You can see right to here, right? Your vision is up. Your vision is up. And you see this and you see this, but you don't see this. And you don't know about that. If you had CBCT, yes, if you did. But you don't know from conventional films. So, the operator only knows there's two.

So, we're living in a question and the question is do they merge? Because we're gonna do it different if they merge and if they're separate it'll be more like—go back to any of my shows. I've talked a lot about glide path management. I better say this right now. We have beat glide path management together to death and we've talked about glide path management in terms of first manual. That was many years ago.

Years ago, long before a lot of people thought it became popular and even copied us and built files, we even talked about mechanical glide path. We've had people on the show like Reid Pullen that’s talked about over about 80 percent of the time you can get to length and most teeth are referred into your office and especially office about 80 percent of the time a mechanical file alone can get you to length.

So, the question is, do they emerge or are they separate? Well, how you do it is you do it just like always. You get in here with a mechanical file because 80 percent of the time it's going to go to length. That means 20 percent of the time it won't. When it doesn't go to length, you can use your 06, you can use an 08, and if you want to, you can even use a 10. And these are all bridge files to get you to a rotary file. Just so you know, a 10/02 a manual hand file is 42 at D16. Just so you'll know, a slider, the mechanical slider from the Pro Taper Ultimate family, it is about an 82 at D16.

Okay. Look at that. Almost twice as big. So, I'm going to use the purple mechanical file regardless of whether I do the catheterization with the manual file or not. I'm still going to go from the manual file bridge back to the rotary file because I'm going to get a little bit more refinement. I'm going to expand the pathway a little bit more. And I’m going to give myself an easier time to start my shaping procedures. We're not talking about shaping today.

So, what do we mean when we say glide path management? Well, what do we say when we mean the canal is secure? All these are words, okay? It means you have working length. It means you have patency apically. The file can slide to and minutely through. And it means you have a glide path. And I'll say a smooth, say after me, I hear you, smooth. Yep. Reproducible. Yep, reproducible, I heard it. It's coming in from everywhere. Smooth, reproducible. Yeah, reproducible. I heard it. It's coming in from everywhere. Put your nose on the handle of the file and you could push the file to length anytime you want to, because you said so. You own the glide path.

So, this is what we're talking about, is securing canals. This is an old lecture. Well, you know that file is loose, you've been irrigating, you might have used RC prep. If you're getting into a tough area, you know the viscous chelators we've talked about them I'll let you go back and look at another show to see their advantages. Especially in more minimalized tighter canals, woody tissue, calcific tissue, stones and stuff. Be sure a viscous chelator slider would go better in a viscous chelator than sometimes in an aqueous. Aqueous is sodium hypochlorite, viscous would be Pro Lube, glide, something like that.

All right, Now, let's take on the harder ones. Usually a little harder, isn't it? A little smaller. You can stop at any time. So, if you're just really floating that hand piece, just float like a snowflake, it'll pull up into the canal in a maxillary tooth. The flutes and the tapers and the rate of change of the taper will deactivate the file, so it's only working over a small portion. If at any time after one, two, or three passes, it just doesn't want to go, again, permission to break out 6, 8s and 10s, suck out, aspirate out all your sodium hypochlorite, put in a viscous chelator, Pro Lube, Glide, RC Prep, any of those work, and you'll end up back here.

So, regardless of the back and forth stuff, we're talking about MB1 and MB2 are now secured. Okay. Now, the fun begins. We can begin to debug the case now. Once we have a smooth reproducible glide path, we can get out our shaper. See it goes purple, white, yellow, red. This is in the Pro Taper Gold family, the Pro Taper Ultimate family, but it follows universal ISO colors so regardless of the system you're using, these are the principles. Just purple, white, yellow, red, whatever.

Okay. So, now that you have secured the MB1 you can shape the MB1. And we end up using a shaper. We go through the first finisher, yellow, 20/07, and we end up with a 25/08. But it's not 8% taper, everybody, over the whole length of the instrument. The 8% is confined to the last three millimeters, from D1 to D3. So, we have reducing tapers and we're about 1mm. About 1mm at the orifice. That is minimally invasive endodontics. You're on your feet, you're coming to the edge of your chair. This is modern endodontics. Okay. So, that's the thing you've got to think about.

Well, when can you fit a cone? When you've got the shape. When do you have the shape? After you've used the last finisher, you might choose a yellow, you might choose a red, but we have a shape when it — 25/08 is parked on the foramen, okay? So, we can fit a cone. So, fit a cone, throw a cone in there. There's matching Pro Taper Ultimate cones, matching Pro Taper Gold cones. There's Wave One cones, blah, blah, blah. Most every company now that makes files has matching cones. Our cones just happen to match better because of the way they're perfected in manufacturing. It has to do with—well, that’s another story. And I’ve talked about that as well.

So, you got your cone fit. So, your question is, you know a 10 file will slide up through here. You know that we had yellow up there, purple, and now we can go ahead and find out will a 10 slide. So, throw a 10 in. If the 10 slides the length, you can sneak it through back and forth, slip and slide, slide and glide. It moves passively over a few millimeters. You control the canal, you own the glide path, you know it's a separate canal. You can go ahead and shape that out. I'm gonna shape it a little smaller because it's in a little smaller aspect of the root like we looked at just a few minutes ago. Remember?

Okay. So, because of that teardrop shaped route oftentimes, a 20/07 is probably appropriate. So, you can fit a cone, a matching corresponding yellow file, corresponding yellow cone, and that cone slides to length and you got two separate apical portals of exit. Isn't it fun? You're in total control and you've treated the canals respectfully, anatomically respectfully, and appropriately.

At another session, at another time, we'll talk about how do we then clean the uninstrumentable portions of the canal. And then that might even beg, how do we fill into root canal systems? How do we fill systems versus how do we fill simple conical shaped canals? It's a whole different game. The thrill of the fill. So, that's pretty much when they're separate.

Okay. Let's look at another cross section. So, you slide back, same kind of a tooth, but we did a little different configuration on the MB. And you can see the operator makes the access cavity. Oh, it's exciting. There's a pretty good sized orifice, MB1. You know this. Why am I even writing it? And over here, we have a really small one. You might have to use ultrasonics to trough a little bit; you might have to use a little orifice shaper to open that up a little bit. We have lots of things in the Ultimate family. I didn't talk about SX shaper X.

But anyway, we have a smaller two, so usually again we as operators take on the easier one first because we know there's communications. These routes are very broad, buccal lingual, and because they're broad, broad routes hold two systems. Oftentimes, the canals do communicate with each other and they speak to each other. And that's the anastomosing.

And so, let's take on that first one, the one that is more usually a little larger, a little straight—more straightforward. You know, not too many dentists over the decades have either emailed me, called me, texted me or sought me out in the lecture and said, you know, how do you get to length on the MB1? That's not a problem in their practices. Their problems and their challenges, like mine, are in the MB2.

So, let's take that on. Again, we could use a 6, 8, and 10. We can change reagents. We can go aqueous. We can go viscous. But at some point, back and forth, you've got a smooth, reproducible glide path. You've got working length. You've got a patent canal. No obstructions. No blockages. Everything is tapered above the portal of exit. Good. It looks like we're getting it under control.

So, we got this MB2, we find it with ultrasounds, we get a stick and through some gymnastics, you know, I know again, we all know. Little effort, little desire, little germination, and you get to length. This is something how that works. The harder you try, the luckier you get. So, let's just say you catheterize the canal, you reproduce it manually or mechanically, doesn't matter. Sometimes both.

But I like to end up again, with mechanical because it's going to take the 10 file and expand the slide path over its entire length. And I have a really flexible heat treated instrument. So, now that's patent. I have a working length and I'm going off my favorite cusp tips. Remember these marks 18, 19, 20, and the shaft is 21.

So, you can use stops. They come with stops. I take the stops off a lot of times because I have a little better visual corridor looking through a microscope. I don't have that donut. Plus the donut can slip around and slide doesn't it? Assistants are always having to adjust your stops. You can go by these circumferential laser etched marks and they are perfect. They don't move on you. So, that's why you don't see a stop. And you got that one catheterized, working length, patency, slide path. Now you're in the old question. Is it a 2-1? Is it a 2-2? Oh, my goodness. It could be a 2-3.

All right. Let's find out. Let's find out. So, which canal would you normally shape as a clinician? You'd shape the bigger canal that is held within the bigger cross-section of the root. And you get a little better shot with your irrigation devices, a little better disinfection with active irrigation. You get your pluggers in there, you can push warm, thermal, softened gutta percha around a little better. So, usually that's the one we shape.

Here it is shaped out. So, you didn't start with the red but you went purple, purple in the MB1. You didn't jump anything, white, yellow and you look to see did I have clean white dentin. Clean white dentin -- it should be loaded on these flutes. So, if you take it out, you know this file just cut its shape. The shape is done. We're not disinfected, we have certainly haven't cleaned, we certainly haven't cleaned, but we have got this path we got the perfect shape.

Okay. So, what do we do when we know we have a perfect shape? When do you fit the cone? When you have the shape? So, what do you do, you pull the file out you take the course line? Red size, gutta percha, master cone, slide up into place, around the curve and it comes into length. It's a thing of beauty. We don't call these points. A lot of your gutta percha is kind of rounded at the tip. It's kind of domed. Some of it is more pointy. Ours are absolutely blunt. They're the size of the file.

So, you want to match up the diameters perfectly with the hold. All right, notch your cone. Notice I didn't notch the cone all the way across the cone. I notched it to kind of have like a unidirectional stop, like the little rubber silicone stops that are on the shaft of these instruments. You know how we curve the file, we torque the stop to be oriented with the curve of the instrument, where it's out of sight? We can't see it clinically.

All right. If you don't notch your cone all the way across, you can notch just the side of it. You can curve your cone and the curve is oriented with the stop. Oh, you love that trick. Okay. Well, if you've been doing that for years, you’re going come on, it’s nice to talk about all together. A few of you are going, gee, they never told me that.

All right. So, you got the cone in. It's nice. Now, the question is, are they separate or are they common? Let's find out. Throw a 10 in. Throw a 10 in. Oh, won't go. I didn't get my rubber stop down to my preferred reference point. I can look at this distance in here and I can even say, oh, it's about maybe three millimeters. Maybe it's three, maybe it's four, maybe it's two and a half. But you can actually see where they merge. If you—okay, don't force the file and don't be turning the file. You're not trying to amputate the gutta percha everybody. You're trying to make a mark on it. So, it’s just in—a little prick, pull it back a half a stop. Pull it back a half a stop. Push it back. No rotation, slide, resistance, just tap it a little bit. Prick it, make a dent.

Okay. That’s what you’re trying to do. Now, what we can do is we can push the stop down and that's going to be our working length. There's no need to be shaping up in here. If we try to shape this one similar to how we shaped this one, we're going to end up instead of having this, we're going to end up having that. We're going to have a ripped foramen. So, we're going to only shape the part that is uncommon. Let's blow that up so you can really see it.

So, when you pull this cone out, you're going to look at the terminal extent of that cone and you're going to see a little indentation from your file. Do not use a rotary file. A rotary file is turning at least at 300. Some of you are spinning them at 500 and 600. You will cut through this like butter and you'll be leaving a cone fit that'll look quite nice radiographically, but it's uncemented.

All right. So, now you know all that, it's quite easy. You have a new working length, an adjusted working length. And we can fit the cone up in there at the full anticipated length. This would be expecting it to go all the way to length, and again, you can see this little discrepancy, and that's this little discrepancy.

Okay? So, what we do is, I like to do this. It's like a double check. It's like I'm on the phone getting a second opinion with AI. Pull. That's your cone. Pull out your MB1 master cone. Pull out your MB master cone and see if the MB2 will slide to length. Oh my, it slides to length and it's a little bit long. Why? Because we've already shaped—we already shaped the MB1 with a 25/08. Well, this is a 20/07. So, a 20 is going to go through a 25 hole, so it's long.

If you said I want to use this as my primary cone during obturation, then you would need to trim this off, and we would then need to cut this one back, okay? But usually, the one you want to pack, your go-to canal, the most straightforward, the bigger volume of reagent, the better hydraulics during obturation, it's going to be the larger system and that's the MB1.

So, in that case, go ahead, back and forth, I like to play this game, you can see it again, but I'm going to go with the MB1, so now I adjust my stop. Now I can shape with white. So I came in here with purple. I'm not jumping go to white go to yellow. I'm intentionally shaping the MB aspect the dis—the palatal aspect of the MB cross section of the root. Let me say differently, the MB2, I'm intentionally shaping it smaller. I'm in a smaller cross section of the root. I need to be aware that this tooth might—I might want this tooth to be there. The patient might expect the tooth to be there for many, many years. So, let's not needlessly weaken the teeth.

So, that's kind of how it works. And now that I've cut that comb back, I have a bigger cross section here because the rest of it was trimmed off. Now, it's back to the reference points, back to the reference point. On another session at another time, we'll talk about how to get these things, both, as I said earlier, cleaned.

Can I just do this for you, please? So, you think in three dimensions. And let's talk about filling or filled. So, we'll talk about that. How do you get the anastomosis? How do you clean out the uninstrumented aspect of the systems? And how do you mold gutta percha and adapt it wall to wall, wall to wall?

Okay. So, I think this is pretty clear. And I think I can end by just saying this -- if you do it like we talked about and you live in a question, you know, most of life is a question, right? You live in the question. The answers will come. They're not always the true ones, but they're the best evidence. And so right now, this is our best evidence.

So, here's your virgin tooth. Here's your virgin foramen. It's a little irregular. It's not perfectly round. Remember, it's anatomical. And if you do what we talked about, you're going to go from a little irregular. The 25/08 is going to give you something that is pretty round. And you're going to have a cone that theoretically is round. And you're going to be fitting round and round. And can you imagine the hydraulics coronal to the cone fit? Whoa, think about what I just said. Think; let's pause. Imagine the hydraulics that you can develop and generate with thermal softened gutta percha when you're matching round sizes with round sizes at the same exact diameter.

So, everything looks good, right? Everything looks just like you would want. Let's look at it when we don't do things with an eye towards 2-1. When we don't recall that it's 2-1 and we treat them as they're 2-2 when they're not 2-2. Well, this is kind of an area where, you know, your F2 would have been, but when you try to sneak alongside it, and they're sharing the apical third glide path, both instruments are, instruments are going to ride on the outer wall, instruments are going to tend to ride on the outer wall, they want to be straight, they're always getting straight, even with heat treatment, they're riding on the outer wall and we're gonna begin to see a little tear. We're gonna be able to start to develop a transportation that we've talked about.

You'll all be going to Ruddle Plus. I'll be there when you get there; we'll have a coffee and then we'll talk about how to manage Type 1, Type 2 and Type 3 transportations in retreatment. So, just to end it, you've got a big tear here. Wet canals, bloody canals, poor cone fit. Why do we even shape? We shape to get taper. We want taper above the foramen so we can control our three-dimensional active irrigation. We have taper above the foramen so we can control our three-dimensional active irrigation. We have taper above the foramen to hold our gutta percha cones so we can maximize three-dimensional hydraulics. All right, so good. Let's keep it good. Let's not go here because that is not a predictable thing for the clinician. More post-operative pain if I didn't mention it.

So, if we just get these out of the way, I have just a couple x-rays, three x-rays, and we're done. So, this is a second molar, merging systems. This was always my primary system. I only did a little work in here. Well, up to the orifice to get this shaped out. But basically, I just treated this as a 2-1, a 2-1. And notice when you have, I'm pretty close to the board, but when you have the neurovascular bundle coming here, you want to have great control. You want a really nice round foramen. As round as you can get. However if you start to have a foramen that looks like a rip, can you imagine the surplus down here?

All right. That's that case. This is just showing, I had gutta percha in files, but this is showing two files. This file probably goes into about right here. So, you can do with a cone. I like a cone because I can see it. When I take out this MB1 file, I can't see that I've scratched the metal. So, this is Ruddle knowing that it only goes to there. So, I’ve adjusted my working length. I've shortened it about that much. I'm only gonna shape to about right in here. I'll shape the MB1 all the way around to the terminus, right to there. And you can see how this develops.

We can get the hydraulics. Notice how we're always getting hydraulics. Isn't it fun to get hydraulics? Isn't it nice to get hydraulics? I didn't even know this offshoot. I didn't even know it was there. And it's about as big as the one I put a file in. So, one of the things is, Schilder's mechanical objectives -- keep the foramen as small as practical. A lot of people think that's old stuff. I've talked about it. The five mechanical objectives are just as relevant today as they were back in the 60s.

So, I think we have one more and this is the last one. So, how are you going to treat these systems? This is 1-2, one orifice, two apical separate portals of exit. This is 2-1, two systems, two orifices, glide path in both of them. And you can see this is coming in about right here. So, that last couple of millimeters is kept small. My puff is discreet. I have corked the tooth. I'm very comfortable with this pack. Very, very comfortable. Long roots. I had to set the film vertically to capture the whole occlusal apical view.

All right. So, in life, they make this pretty easy for us. I got grandkids and they're driving now and they're telling me there are signs out there and those signs are messages. And as we get older, we don't see the signs. We see them; but we see them subconsciously. I want you to have your endodontics be subconscious. Your thinking, your planning, but it's like breathing, it's autonomic. Thank you.

Okay. So, we're gonna close our show today with a Ruddle flashback. And we mentioned in the opener that it was going to be—we're going to actually tell the origin story of my dad's snake phobia. So, I've known my whole life that my dad hates snakes and my mom hates spiders and we don't really talk about those two creatures that much. Like, it would not be funny to give him a can that you open the lid and a snake pops out. That would not even be remotely funny.

That would be a certain death.

Like, even for work and on The Ruddle Show, I don't wear a snake skin print because I know that might bother him. So, there's two things that happened to you in your teen years and they've kind of influenced your whole attitude about snakes going forward from then on. So, why don't you tell us those two stories?

Really?

If you can.

Okay. Now, you get over this stuff, but I don't like snakes. Probably what happened first, I didn't really have an opinion about snakes and I was going to—well mostly to say high school, but it was called an academy and it was a religious school. And so, my emphasis there was basketball. So, I was on the basketball team, I was playing some great ball with wonderful teammates. And so, I decided when I came the next year to this same school, I wanted to room with the forward, Henderson, because Henderson was the forward on the team and I was the guard, and we could just talk endlessly at night about games, moves, X's and O's.

So, we're rooming together. He's got a bed, I got a bed, one room in the dorm. And about 2:00 AM, I believe, there was a knock on the door. It woke us up and then the door slowly swung open. I don't remember, but I couldn't see very well. It was dark. Curtains were pulled to keep the lamp out from outside. All of a sudden I could sense something was flying through the air and it landed on my bed. It was supposed to land on Henderson's bed, just for the record, but we had switched, and it landed on my bed, and so big deal. Probably sand, whatever. Wouldn't have been a brick, could have killed me, right?

All of a sudden, the bag's moving, and it's moving pretty violently. It's like, I know that something's alive in there, and I didn't like that at all.

And it was a snake.

Later we found out it was a snake because I opened the window and threw it out the window. And then, the next day in the Vesper service they said, who is putting snakes in bags and throwing them around the dorm? Anyway, that's not part of the story. And then you can just skip. So, I got out of high school finally.

And then I was, one of my first jobs I was working for Pacific Gas and Electricity, PG&E Northern California. They bring all the power to like San Francisco, Oakland, the Bay Area and blah, blah, blah. So, I get my first summer job and the reason I got this job is they need a dummy to walk way ahead of them, maybe as far as 500 yards. And we were shooting in towers for these cables to lace the Bay Area together.

So, there was a bunch of guys behind me. They were the engineers. They had a track that they could shoot and they could tell everything. And I had to go out, like I said, four or five, 600 yards ahead of them. And when I got to the right place, they would signal me and then I was supposed to turn around and hold this stick up that had marks and when everything was fine, you know, they'd wave the flags and we'd all move forward. So, I never basically all day saw the crew, but we all came together in the morning with a truck.

So, since I was going first, I, they were around the truck, they were having coffee, I took off. And I had to go through the first gate of this property. So, I opened the gate and I go through, and just on the other side, there was a snake. And it was coiled up, because I had really, I guess, made him angry. I never saw him. He was against the dirt, so he looked like—and then, I saw him immediately, he was about probably 10 feet away from me.

Well, I got my shovel together and I killed the snake. And that was not easy for me. And then, I decided I do not want to see this snake ever again. I'm going to bury the snake. So, I made a shallow grave, I don't know, two feet enough to slop them in there, put the dirt over them and was muttering to myself as I walked away, what a great day this is going to be. So, we did the whole day, you know, came back, we're coming back now, the guys are ahead of me because they're behind me, so they're going back to truck, I'm coming from further away, and when I come across this path where I had buried the snake, the dirt was out of the grave and the snake was still moving a little bit and it really pissed me off. It was very unsettling to see a snake I had cut and removed his head and it was still moving and this was hours later.

Yeah, I don't know if it's the same for snakes, but I think they have like several hearts maybe. Like I think worms have maybe five hearts or something. I think I remember learning something like that in school. So, if you cut them up, the pieces still move.

Well, this is why I didn't really like the Dentistry Emblem. You know, there was a snake feature.

That's why you had no curiosity to delve deeper on that one.

I did not delve deeper into the berries and the leaves.

Okay. Well, thank you for the story and I think we all understand you a little bit better now. All right. Well, that's it for our show today. I hope you enjoyed it and we will see you next time on The Ruddle Show.