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Well I guess. I don’t know if I’m going to fall off. I’d better steady myself. I guess I’m so taken aback by the compliment that I fell off my chair. But I came back; he’s back!

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

How you doing?

Pretty good. What about you?

Excellent. I hope everybody out there in Endo Land is doing terrific!

Okay, so are you looking for a good book to read going into the end of 2023? Maybe you’re thinking mystery, science fiction, romance? Or how about a motivational book? This list behind us is a list of some of the top motivational books of all time. And by motivational, I mean that these books have been known to drive readers to change and improve their lives.

So you’ve read a lot of the book son this list, haven’t you.

I have.

Do you want to make any comment about that?

You’re trying to squeeze a little lemonade from the lemon, yeah. Yeah. I’ve read most of them because I got out of dental school and then I went to endo school, and there was a little hiatus between those. But anyway, I came out young, but I thought I was well trained. And I realized very quickly that I needed work on relationships, on communication, on goal setting, and just generally try to get to be a little better person out there. So that wasn’t carved out at the University of Pacific in San Francisco, nor at Harvard. So it was just sort of a natural progression to try to get a little bit better.

Several people have influenced me. Omer Reed; I went down there with my team. That’s important to take your team with him. Tony Robbins comes to mind. I read his book first, Unlimited Power, and then #5 up here I read second, and then I got the tapes. And that’s because I took the whole team to Los Angeles to hear a day with Tony Robbins. And the reason you want to do this – you want to do this; I want to do this – is because it helps us see things from a different perspective. We get so caught up in our four walls and we’re working and there’s patients and there’s responsibilities; but to the extent you can reframe things and you can set goals and create some ignition with the staff and momentum, you can get to different levels in your practice beyond just going around a curve and doing a nice job.

So yup, there’s lots to say; I could add more. But one of the main things I learned from him was the little conversation right now that’s going on between your ears – like will he stay on script please – the little conversations between your ears is how it is. And so how do you communicate silently? This quiet communication that’s always being played like a continuous loop; that’s pretty much who you are. So think about changing your conversation. Change the result.

Okay, well I must confess that I have not read any of the books on this list. But if I was to pick one, I guess I am kind of drawn to #1, The Power of Positive Thinking. Apparently science has shown that a positive attitude can really improve your health, your longevity, and just make you more successful. Also, apparently this book talks a lot about the importance of taking action, and that basically any action is better than no action at all. So I need to read this book to help out a friend, so I’m going to do that.

Okay.

Yeah, I just need to help out a friend. Okay, well if you were to add a book to this list that’s not on the list, is there a motivational book that’s been motivational for you that’s not on this list?

Yeah, I’ve read a lot of books; not only from these “gurus,” but from sports figures, athletes, how they get to that next level? Because at some point, every athlete has – like in tennis they have the backhand, they have the forehand, the top spin, they have the second serve that kicks, they have the slice, they have drop shots, they have overheads. So they all have that, so how do they win? Well Pat Riley wrote that book, The Winner Within. I’ve talked about it before and I won’t go into it in too much detail. Or as you said, I will. No, that would be a long, long opening wouldn’t it?

But I talked a little bit before about just things he talked about in terms of being better, just little tiny things. Do you remember that; that little part back in the previous season? Just 1% here and 1% there and 1% and all of a sudden you’re a different person. You’re playing above the rim, to use his basketball analogy.

But I liked Chapter 2, and I guess I’ll just say a word or two about Chapter 2. Chapter 2 in this book The Winner Within was the disease of me. And that’s what sabotages organizations, it sabotages dental offices, it sabotages countries, societies. It’s greed, selfishness; sometimes people win, but they’re not prepared to win. I mean they won; can’t take it away – they won. But they had inexperience in winning, so therefore all of a sudden they might feel they need more. Or they might need the last shot of the game, or they might need to be the hero. And we need to get into our selfless roles, because it’s not about me or you; it’s about the team. And we give up and sacrifice for the greater good. So that was a great chapter to read about the disease of me.

Okay. Well I guess for me, a couple books that I’ve read that I really was inspired by and found – they’re not necessarily motivational books, but they tell you a lot about how the world works and it helps you to kind of see patterns and stuff. And patterns are important; we’ll talk about that later.

Oh, tell me.

No, we’ll save that for later.

No, I mean this book. What was it?

One of them is Zen and the Art of Motorcycle Maintenance, and I heard about that -

Zen and motorcycles? Wow!

I heard about that from Phil Jackson who was the coach for the Los Angeles Lakers. And he said that book really inspired him, and so then I wanted to read it and I read it. And it’s really good in that it helps you to see how people perceive things differently.

Was it really about taking an engine apart?

That does play into it, because he’s actually on a motorcycle road trip; the author of the book.

Oh, okay.

But we’ll go into it in too much detail then. And then another book that’s been really influential in my life is Outliers, and we’ve talked about that a lot on our show. And it’s just interesting how they present success as this serendipitous coming together of luck and opportunity combined with practice.

So anyway, those books have been motivational for me, just because for me when you have a better understanding of the world and how people see things, to me that is motivational. So are you motivated to do a great show today?

I am. But I loved that little line you snuck in there; I don’t even know if they heard it. But luck is where opportunity and preparation meet; just remember that.

Okay, well let’s get on with the show.

So today we are introducing a new segment called The History of Endo. And I know one of your favorite expressions is “everything old is new again.” And I’ve also heard you say many times: to create a future that is not about the past, but that takes the past into account.

Yeah.

And this sentiment is also echoed by other greats, such as Confucius, Albert Einstein and Carl Sagan to just give a few examples, so you are in good company.

Well I guess. I don’t know if I’m going to fall off. I’d better steady myself. I guess I’m so taken aback by the compliment that I fell off my chair. But I came back; he’s back!

All right. So you might be wondering why do you study history? Well it’s important to study history because it allows you to see patterns that might otherwise be invisible in the present. And it also helps you to then understand the present more and see where the future might be headed. Do you agree?

Yeah. I think – well I really am strong about knowing the history. I see so many young kids today and they just know their instructors. That’s where it all started. So if you look really back in the rear view mirror, you start seeing patterns; you mentioned that earlier. And patterns are everything and that has to do with your instincts.

So my instincts tell me, if I’m looking at the past – we talked about this earlier – but 1970s, was Hydron. And of course it was brought in by an academic, well-respected chairman at a prestigious school in Boston, so everybody thought Hydron might be the ticket; some did. Well then that got us through several decades, and then we revisit Resilon; same thing. Another academic, chair at a school, very prestigious school, and a lot of his followers, especially his students, jumped on the bandwagon, and it had to be a monoblock and it was going to bond. We didn’t learn anything from Hydron, did we? But we could have.

Well that brings us right up to minimally invasive endodontics. I just skipped a whole bunch of things that I could just go back and beat to death, there are so many of them in my mind. But minimally invasive. All of a sudden saving tooth structure was important; sure is. But there’s no science, there’s really no evidence, there’s no papers that show what success looks like in 5, 10, 15, 20 years. Just blindly jump in the pool. Let’s make skinny preps, that was a lot easier too. Well then that created more problems; that led to single cone. And all of a sudden we needed new sealers, and all of a sudden the sealers are very sensitive with remnants of other irrigation reagents; sodium hypochlorite, EDTA, CHX.

Anyway, there’s a lot of rushing into things that we didn’t learn from Hydron, we didn’t learn from Resilon, now we’re doing it with minimally invasive. Single cone, bio ceramic sealers. What else did we get here? Oh, and then we had to invest in $100,000 technologies to clean these really underprepared, only instrument, not cleaned, not shaped; we needed technologies to clean them. And we realize now that there’s not agreement on that they even do the job that they’re intended or purported to do.

Well yes, exactly. So we’re seeing patterns. And then you also study history because even though your daily life might differ from the people in the past, a lot of times you’ll see that the goals and objectives and values are similar still.

So anyway, today we are going to look at the 1948 article -

1948?

It’s called “Save the Pulpless Tooth,” and it’s by Dr. George C. Sharp. Now I couldn’t find a lot of information about Dr. Sharp, but I did find that he was one of the original and founding members of the AAE, that he served as AAE president from 1951-1952, and that he practiced out of Pasadena, California.

Yeah, yeah, he was in California.

So how did you come across this article? You gave it to me, but how did you get it?

I have no idea. To be honest, I have a folder. And a folder is just old, I think fabulous articles, let’s just say from across the decades; even before Ruddle was a dentist. So I liked some of those old articles because they give so many insights into what we’re trying to do today. And having been an inventor – you have to start going back to see what others did, so you can get a little better than they were – you start to realize a lot of these people were thinking about the same things we’re thinking about.

So back to this guy. You mentioned Gladwell and Outliers, and how we had to be born at a certain time. So by the time we became a professional man or woman, we were like in the world as it existed at that time in endodontics. I just want to point out a few things – I hope you’re finding this very fascinating; hold onto your seat please. So we’re talking about instincts, we’re talking about patterns, we’re talking about everything old is new again. He came along at a time – 1864, rubber dam; 1884, local anesthetic; 1895, Rankin and the X-ray. Oh geez, 1917, the year my dad was born; sodium hypochlorite. Dakin solution, Hess; 1925, Walter Hess. And then finally antibiotics didn’t come along until 1928 by Alexander Flemming. So if you throw all of those things I just said in there and you look at this article and you see the cases this guy was doing. I mean his post-op films look like Star Wars. I mean it looks like what everybody that’s using GentleWave is trying to do today.

Okay, well he starts off the article by talking straightaway that root canal treatment is justified; that over 50 years of successful root canal treatment shows that the extraction is unnecessary, and that you have patients who have 35-year recalls showing successful endodontics.

Can I just interrupt? His work was published in ’48, but she’s talking about work that was done in the early teens.

So he does say that there’s a few criteria that are necessary for endodontics to be successful, and the number one that thing he says is a rubber dam is a must. And actually when we were doing a podcast on the standard of care and technology, we were looking through the whole standard of care statement on the AAE website, and really the only technology we could find that is absolutely required is a rubber dam.

Yeah, don’t look for a microscope or a high-speed handpiece. Look for the rubber dam from 1864.

And then secondly, Dr. Sharp places a lot of importance on using sterilized instruments, and also on disinfecting the canal; which these are things that are important to us today as well. So a lot of the medicaments and instruments that he talked about are clearly of the olden days, but a lot of the goals and objectives are the same as now. Correct?

They’re absolutely the same. In fact it’s so fun to read the old articles. I know you don’t have time, but I guess as I approach 1000 years old, I have lots of time. But actually, rubber dam isolation; you already said that. But that was one of the things he attributed to his success. He said not just have access; he said have free access. How about that, free access? Maybe straightline access, I don’t know. He talked about don’t push files; don’t grind files. He actually speaks about this; it's very passive. We have our terms today, but the terms today are just to remind the audience of how we’re thinking. Like Schilder said, bounce off resistance; so I like that. He said make a final preparation that can be what? Wow! Three dimensionally clean and disinfected and filled. And he knew about systems because of Walter Hess. So he shows – you have the paper; I have to paper – he shows root canal systems on post-operative films, so that was incredible that he’s thinking like this. A shape that is conducive to be cleaned and filled, they love that. Guess what? All canals need to be open and patent apically. Patency! That preparations, he said, must be patent in their terminal extents. Wow, sounded like Schilder to me, but it was coming from 1948.

And finally, disinfection. And I mean he had a way I think – I’ll talk about it later – but there was a very special way. Just like today with Endovac, I’m finding people; where’s the Endovac? And GentleWave, is it a laser, is it smart like Pro EndoActivator; is it a plunging cone, is it hope, is it prayer, is it on your knees? But he had ideas.

Yeah, I mean he does really emphasize. I remember what you were saying about patency; that you need to shape through, minutely through the terminus. Like not short; he said to actually go through. Because he wants to – there was a lot of -

Oh, maybe I missed something.

No you didn’t. I just was expanding a little bit. Like the importance of drainage. So he really wanted that to -

Oh. There’s fluid that accumulates around the terminal parts of roots, especially in infection. And he recognized, just like it’s axiomatic in medicine to I&D, he recognized the I&D is through a patent, open terminus. And fluids that accumulate could flow back up into the prepared canal; there was available space. And he would sometimes bring people back 2, 3 or 4 times to keep draining badly abscessed teeth with big radiographic lesions.

Yeah, that was interesting.

Remember, no antibiotics back then.

Okay. I see that Dr. Sharp then says: “Readiness of the root canal for permanent filling can be determined either by a bacteriological test or by observing the tips of the paper points used.” And so now moving on to obturation, I see that he uses softened gutta-percha, but he doesn’t soften it through heat; he softens it by chloroform.

Yeah. Again, there’s people smarter than me on the history of endodontics. There’s people that have written books. In fact, if James Gutman is out there, Bellize from Washington; these guys have written about the past. But I want to just talk about Callahan and Johnston, 1911. So this is his era, right? He published in ’48, so he would have learned in 1911 about this famous technique where they used chlororosin and had it inside the canal. And they took the master cone and put it into that, and it would chemically soften the outer part of the cone and they could move – chemically softened rubber, they could move it everywhere with their sealer. So pretty exciting fills; pretty exciting fills. And of course we learned later, at times there was quite a bit of latent shrinkage as the monomer evaporated off. So that led Blayney and Schilder and that whole group to begin to thermal soften it. And by heat softening gutta-percha, it’s readily moldable; you only have to heat it 3° above body temperature from 37°, 40°, to get a thermal softened material. And the whole key was to put a load on the cooling gutta-percha to offset shrinkage. So in his work – I know you won’t believe this – but in the Boston University Library, if you load a cooling material, you’ll actually get a little net expansion; and it has to do with it’s a C5-H11 hydrocarbon; it’s a rearrangement of the molecules.

Okay. So when you were reading the article, was there anything that struck you as very different from how endodontics is done today?

Well I don’t know if you’re setting me up for this or I’m just a little behind in our sync here, but he also found that filling flush – which is actually a little bit long radiographically – was the highest success rate. So that agrees with the Swedish literature. It was the Scandinavian literature that it was always short; short. Don’t go through the foramen! It’s heresy out there! Modern medicine just borrows from – dentistry borrows from medicine and we know that enucleation, incision drains is the key to success. So basically, filling flush was removing everything; and there might be a little surplus that was biocompatible. So I liked that. He didn’t find short fills were good, and he found that there were more problems with it. And then of course extremely long overextensions weren’t good. Schilder made all these critical distinctions in the ‘70s; the so-called overfilled cases typically internally underfilled. So you have an overextended cone with space; internally it’s leaking. So make the distinction between long and filled 3-D, and overextended and underfilled.

Okay, I see. I jumped ahead a little bit, so I didn’t know you were going to say that. But yes, I do see that that is actually very similar to today, how we view the sealer puffs, and differentiating between an underfilled canal that’s overextended and a 3-D filled canal that’s a little bit past the terminus. But when you were reading the article, was there something that was really different that you noticed from today?

Oh. Well, I noticed he didn’t have penicillin until much later in his career. But I did see that he would have people back multiple times for drainage if that’s what you’re getting to, and that was to relieve pressure apically because he didn’t have antibiotics and he would never leave a tooth open. See I don’t have any problem leaving teeth open. We were trained to leave teeth open. The key distinction that I’m not hearing is for 24, 48 or 72 hours. He would not leave a tooth open, but he was sort of leaving them open when he had them come back to the office, took the restorative out of the top of it and let it drain. And then he would flush it and go through his electro medication cycles again, and then he would close the tooth. And then when they were asymptomatic, he’d fill it.

Okay, so a lot of times it was multi-visit; not just two visits but maybe many visits.

There were many visits back in the day, that’s right. So now we’re pretty much with our technology, with pharmaceuticals and stuff, anti-inflammatories, antibiotics and stuff like that, there’s more than one visit and it’s in the books forever. It was proven in the ‘70s, that was a long time ago; but back then they didn’t have all that knowledge and all that technology and all those pharmaceuticals.

But it is kind of nice that it could be done without antibiotics too.

I thought it was cool. I don’t know if the audience wants to hear this, but he disinfected every root canal, whether it was a single tooth or a multi-root tooth, 30 minutes. Two 15-minute cycles. And he would take a zinc wire, the positive pole was put down into the shaped canal, the canal was loaded with a solution of saline… sodium chloride, salt. Then the wire came out of their mouth and he put in a sponge; the sponge was dipped in salt and put on their cheek; and he liked to run about 1, 2 or 3 amps and the patient controlled the whole thing by signaling if it was too much or too little. But he loved to do about 1 or 2 amps, and he did it for 15 minutes twice. And that probably had a lot to do with his filling success with the chloropercha.

Okay, well let’s move on now to healing expectations back in 1948. So Sharp states, “My experience with badly infected teeth treated according to this procedure has been that in from three to twelve months, the bone regenerates around the tooth.” He also notes infected teeth seldom cause pain after filling. So would you say that both healing and pain expectations are in line with the state of endodontics today?

Absolutely! I mean the quest for the flag, right, the championship, the final goal, the filled root canal system. And we do all these stunts to replicate what others before us have tried to blaze on the trail to success. And so what is funny to me is you start seeing that three months he saw radiographic healing. Can you imagine? He must have held the film for like 15 minutes. It’s healing! Well what does GentleWave say? All their three premises have never been proven. Healing radiographically is very fast. Patients are more comfortable and there is greater long-term success. I’ve even heard in the older days, standard of care; a new standard of care is being discovered and developed. None of that is necessarily true. When you look back almost – what is it, 100 years ago some of his work was being done; the early 1900s. Over about 100 years ago and three month healing? How about that fast healing paper in six months by GentleWave? It kind of makes it like a chuckle. And we’ve noticed that to any practitioner that it’s open and patent, it cleans well, has a nice deep shape, is getting rapid healing. So it was important back then and you can see some of the companies today have thought it was pretty important today and maybe they can nudge it to faster healing, but it’s about the same rate as slower healing.

Yeah. I mean I just really want to emphasize that 75 years ago they were seeing some fast healing at three months.

Interesting stuff.

Okay. One thing I also want to address is his last paragraph. It’s pretty short; I’m going to read it. “Drs. Ricker, Coolidge, Blayney, Grossman, Marshall, Johnson and Walker use methods that differ somewhat from each other, but they all get good results. The method described here has proved the most successful in my practice over a period of more than 50 years.” Now this really struck me because this is what we’re always saying on The Ruddle Show. We’re always saying we’re showing you Ruddle’s way; we’re not saying it’s the only way, but it’s the way that’s been successful for him. And we just really want to emphasize that other clinicians might do things differently, but they can still get good results.

Yes. So to bring it back around; GentleWave people, you should be encouraged. You’re now paying $100,000 and you can hook a hood on top of a tooth. And for you, if that works – hey, some of them are pretty passionate about it. Well let’s just give them a round of applause. I see laser people getting great results. And if you can make a little smaller prep and use a laser and leave more dentin, that’s a round of applause. So all together, we all try to go forward and we’re all passionate about what we do, and of course we all think we are the truth. But the fact is he was a great guy. Like if you went into a Hall of Fame of endodontics, they would certainly be some of the people you’d see in the Hall.

Yeah, there does really seem to be an attitude nowadays to make another person wrong to make yourself right.

Well this is a big point.

I really like the expression you always say: a rising tide raises all ships.

I think so. I’m old, maybe, for some of you out there, but I can remember the days where you’d have heated debates, onstage in big rooms before large audiences. And afterwards, you’d go and have a beer. But now, there’s this separation and there’s bickering and there’s camps and there’s political ties and connections and financial stuff. It’s a different game today, but actually we should all just learn from each other.

Okay. Well that was a good discussion. I think what I most learned is that although the technology is completely different than it was 75 years ago, or very different, a lot of the goals and objectives are the same. And going forward now into the age of AI and lasers; I mean maybe healing – not healing – maybe treatment might be more predictable. Maybe there might be less of a chance of human error, like with AI. But I imagine that going forward, that still our objectives and goals and values will remain largely unchanged.

Yup. So we’re probably more alike than we are unalike.

All right, thanks.

Today’s topic is identifying the MB2. I don’t know about this word, “elusive.” I don’t think for many of us it’s that elusive. It’s just a canal that needs to be located and negotiated and shaped and disinfected and filled. So that’s just like any other canal. But it is a topic we’re going to revisit. I’ve done this before on The Ruddle Show, but I understand it was many seasons ago. And then there’s a lot of people that write in and they want to know how to find canals. Probably the elusive one would be like a mid-mesial of a mandibular molar; or maybe some other bizarre anatomy that you’re thinking about. But I think if you think about the decades of all the writings, the books, the chapters, the various lectures you’ve seen, pretty much were in recognition that a lot of these maxillary molars have a second system harbored within the MB root.

So that’s a little bit of a comment about it. You can see in this animation, you’re kind of seeing the DB back in here and we’ll get rid of that one. But you’re looking at a view you’d never really get to see with a conventional film. It’s the proximal view and of course that root. Just keep thinking during this entire presentation; that root is like my hand. If you come straight on, that root looks pretty narrow mesial to distal. If you come off axis horizontally, the root begins to get wider and wider like the hand. And broad roots commonly hold two systems. If you think about vasculogenesis and how morphology in teeth even develops, then you would be wise to know that it takes pulp to elaborate dentin. So if you find these great big ribbon-shaped root systems, you’ve got to recognize there’s probably going to be two canals in them.

All right. So a comment to make about this tooth is it’s probably what? The biggest tooth by volume is probably the most researched tooth in the mouth, and it’s definitely the most misunderstood tooth. Probably the biggest cause of failure of a maxillary first molar are failure to identify and successfully negotiate and treat the MB2. I’ll give you a little statistic in a little bit about what others have said, its incidence and frequency, are the merging, do they divide or are they separate and all that. But really, looking going through the animation you can move right to Frank Paque’s beautiful micro CT images, and this is just two of them. But you can start to notice the plexus; the anastomosing between systems and another apical, separate portal of exit. And then of course if you look at this one, it’s like a Christmas tree. It’s like Star Wars. Look at all those opportunities! I see them as opportunities; you see them as like – well challenges. Look at it as fun.

So the next thing I want to talk about; there’s going to be lots of ideas. There’s going to be 14; 14 concepts that I’m going to identify that can be utilized to find these. Lisette talked about this earlier. About looking for MB2s, there’s different ways to approach it. There’s different mind things, there’s tools, there’s armamentarium. But I want you to understand that one of the most important things is access. And of course I’m not talking about Ninja accesses and I’m not talking about orifice directed accesses. Those are fine. And I’m teaching to the masses, so if you say I have a microscope fully employed; if you say I have CBCTs; if you say I’m Houdini and if you say I have lasers (I like the laser better than the other one), well then you can probably do a lot of things a little different. But that’s not how the world of dentistry approaches endodontics. Most people don’t have all that stuff, and even those that do can benefit from having an access that’s not too big; it’s respectful in a concept and age of minimally invasive endodontics. But it’s also not too big. So not too small, not too big; just right. And just right means it allows you, the operator out there, to identify it. So that’s a big part of this is getting in there and having the appropriate access; one that understands the MB root anatomy.

Probably one of the most important things if you’re going to find it is you have to believe it’s there. If you don’t believe it’s there, or you think it happens just to cowboys in some other country, then you’re never going to even look for it. And 13 of the ideas I’m going to give you, you’re going to say I don’t really need it because it’s so rarely there. A lot of you will have the conversation; well even if I’ve been missing them, my cases aren’t coming back. My patients are asymptomatic; everything’s fine. Are you sure about that? Are you sure they didn’t get to another office? I’ve made a living out of retreating people that were swollen with missed MB2s.

All right, so that’s a little opening. Let’s look at this one on the bench. You know, I’ve held a lot of teeth, thousands and thousands of teeth in my hand around the world, for decades and decades and decades. And you just see this on colleagues’ teeth. So colleagues bring in teeth to work in the workshop, and I love to spin it around with my gloves on and show them that MB root. And before they ever start it’s like whoa; whoa, I never saw that before! Well, now that you’ve seen it physically, now that you’ve got the autopsy on the bench and you’re looking at it, if you don’t like you’re results, change your approach. And your approach could be wow!

So they don’t all have MB2s. I can tell you honestly that I’ve treated quite a few molars over the years where if you waive risk versus benefit, you’re just not going to pick up a second orifice off the pulpal floor. But look at the fun if we push in on this one – and I think they should just push in for an hour, don’t you? I mean that’s a plexus. Write it down. If you can’t spell it, that’s a network. Wait a minute. That’s a system. That’s a root canal system.

I’ve got a colleague from a foreign country, a very nice man. And he said that his girlfriend is listening to the tapes and she hears the show, and she said she loves how Ruddle says “systems.” And now they’re using systems back and forth about other ideas in life. Like look at that traffic; it’s a system going down the freeway. So we have a system there, plus it’s a network.

Now how hard do you look? There’s hands all over that. Oh Cliff, couldn’t find it. What do I do? You have to weigh risk versus benefit. You’re not Ben Johnson, you’re not John West, you’re not Herb Schilder, you’re not anybody, you’re yourself. And you’re there chairside and it’s you and the patient. And so you go as far as you’re comfortable. But you should have training and you should understand a lot of ideas that we’ll talk about.

Here’s the drill path. The drill path did not result in Ruddle picking up a catch. So at some point, irrigate like crazy. Flood these things. I loved that 1948 paper; he was flooding, he talked about flooding. You know, flooding. A lot of you are doing a whole root canal through an access cavity with three drops out of your CC syringe. You’d think it was like liquid gold, but it’s the cheapest thing in the office.

So anyway, you drill. And if you start to feel like you’re not comfortable, you’ve taken some films, you’ll notice the measurement from the occlusal table down the pulpal floor, you’re noticing that you’re below the crest of bone – a little infrabony pocket maybe. But the drill path is up here. So you can begin to see – I don’t know if you see this, but I’ll get this out of the say so you can see your best. But I see that, and I see that. That’s the concavity. So you don’t want to go through the furca, you want to cheat a little bit out that way. But let’s remember, that root is like a kidney bean. And it’s wider over on the buccal and it’s narrower over here; and you’ve got something here and you’ve got a groove a lot of times off to another canal. So let’s learn to know what’s underneath that clinical crown. Let’s begin to visualize that root.

All right. So lots of anatomy; lateral canals, multiple portals of exit. And we’ll go back to this mode, but you can see the lateral canals, multiple. Look at the curvature and the recurvature, and again exits, exits. This is endodontics. So learn to trust your reagent. Sometimes Ruddle can’t find everything, but if you’re shaping well in the MB1, your throws and interconnectors, you might surprise yourself when you use a hydraulic filling technique that’s not called a single cone.

All right. So let’s start getting into this a little bit more. I want to really emphasize this guy, John Stropko, truly a gypsy. We just exchanged a few words here, just a few days ago; it was really a thrill for me. So John, if you’re out there and you’re watching; I hope you don’t get near snowmen and keep the big vehicle off the high mountain passes, please.

All right. This is pretty shut down. The floor, the pulpal floor and the pulpal roof have almost coalesced. So you know measure twice, you can only cut once. The root looks pretty simple. You’re saying yeah, I know. I can see a little wave in the root. But you can see it in there, you’ll get in there, Class I, let’s roll. What does Stropko show?

Stropko looked at stuff. He looked at about 1800 cases. I’m kind of – John, if you hear this, give me a little grace – 1800 cases he did over about 8 years. And I wanted to just save this for slow motion. There’s a pre-scope part of the study that was published in the Journal of Endodontics, and then there was the scope portion. All right? So pre-scope he was finding about 73% MB2s. When he got the scope the numbers began to climb, and it’s all explained in the Journal of Endodontics, and he got to 93%. So that’s a pretty significant jump by just having vision; lighting plus magnification. So that’s pretty interesting. What you want to know when you miss them is well they just all join, right? So if they’re in my practice and I miss them, they join for sure, guys. If they’re in your practice and they’re missed, they’re separate. So how many times in a root do the canals go up like this; they go up like this and they join? Okay, that’s one idea. That’s one idea.

Now we can come back and say well, what if they go like this? You’ve got something that comes up and around like this, and something that looks like that. So this is two or more separate apical portals of exit. So he gave us the numbers on that, and I’ll get this out of the way so we can – oh, I guess I better do this just to be clean – but he showed us that out of the 45% joined, 55% were two or more. So greater than two portals of exit apically. So we went from 73% to 93%, and we can see about 45% joined and about 55%; you want to get it. So that’s more than half the time.

So I think with just one paper – there’s many papers. I’ve left many of you out and for that I deeply apologize. There are so many papers on MB2. Remember I said the most researched tooth in the mouth, the most reported tooth in the mouth. I liked Stropko’s paper; it was a very, very nice paper.

So you can see all the adjacent teeth, big pulp chambers, and we’re doing endodontics on that. And we’ll just cut to the photos. There’s before, you’ve fallen into these teeth. We took out some amalgam just to see if there was a was fracture that came over the marginal ridge; there wasn’t. OK. Maybe a little superficial, but nothing down the axial wall. And of course you see this classic groove, the classic groove, emanating off the MB1 off towards the palatal. So when you see all that – this is bleeding; it’s a vital tooth, blood’s falling out of the MB1 and 2 and the interconnector. And then if you just look at a before and after shot; this is after Ruddle did the cleaning and shaping. We lost a little bit more of the amalgam out here that fell out. But my clamp was below the alloy, on tooth structure. So we continued. I still had a reservoir because I really need irrigant.

I guess you’re starting to understand, if you want to know what the big technological trick is. Well the big technological trick is have a reservoir and have it flooded with sodium hypochlorite at all times. So there you go. So that would be about the before and after, and you’re looking right down on it.

So your accesses, some of you would say – I’m sure Brent Heber would say my God, I could climb in there myself and all my family, and we could probably go on a vacation it’s so big. It’s like – well I’d charge Brent a lot more, because I’d charge him for extra bedrooms it’s so big. But a lot of you aren’t finding them because you don’t have an access that allows you the freedom to take off the roof to find the groove that runs to the lip, to the orifice, to the MB2; that’s what you’ve got to learn to do. And these are steps I’ll show.

So the post-op is not remarkable. That’s what we started with, remember, the Class I amalgam. These merge and exit as one. So if you know that they merge early – and that’s another lecture. We can put gutta-percha in the MB1, we can put a file over in the MB2, take the gutta-percha cone out, see if we left a mark by the tip of the file in the cone. If you know that shrank down, restrict a little bit your shape in your MB2 because you know it merges in there. And you’re not going all the way to the terminus and worrying about multiple apical portals of exit.

So nice clean case, and it’s a case that everybody that’s watching could learn to do. Remember, Ruddle Endodontics is transferrable and you don’t have to go out and buy everything in the world to pull off a root canal like some of our colleagues would lead you to believe. You’ve got to have this, you’ve got to have that, you shouldn’t even be doing endodontics if you don’t have some of this technology! Rubbish! You just heard about the 1948 paper, so you realize a lot of success can be had with a lot of different ideas.

So we’ll go right on; here we go. This is one that is very calcified. I take a lot of crowns off; I just told you another trick, didn’t I? Anatomical familiarity was one of them. Straight-line access was another one, complete access. Another one was take crown’s off because you’ll have better orientation. You’ll be able to see the emergence profile of how the tooth exits the gingiva. And then you’ll have better orientation. But you don’t know how this abutment is, just to be more dramatic. Yeah, I’ll go with black. You don’t know if the abutment is like this, it could be tipped like that, the abutment could be over here like this; you don’t know.

So you make your access in accordance with what you’ve got. And what you’ve got in this case is get the crown off. So I got the crown off. So I get the crown off; I now can see quite well. Notice this. Notice. Classic. And then the little groove. And now you notice that we’re getting a long ways over towards the palatal. Look at how brown this is; that’s floor. Notice the brown row to the palatal root. Notice how it’s brown over to the DB. These are all landmarks.

So I’m using ultrasonics; that’s another idea. Ultrasonics to drag a bowl along this groove to uncover. Because we all know, if you’re finding these things, you’ve got to carry your access mesial, at the expense of the mesial marginal ridge – oh my God, the minimally invasive people are going crazy, but that’s how you get it. So would you rather have a little more tooth structure and miss a system? Or would you rather just get everything and use restorative dentistry concepts and restore these teeth to solid health?

So look at how this then moved up to where we could actually treat it. Was it important? Did it merge? No, this one did not merge. This one ended in three portals of exit. So this one is your MB2. Okay, my daughter said do we want to do it this way today? We’ll do it different down here, just so you’re having fun. This is an MB1. But notice we have a significant portal of exit.

So basically you have to assume they’re always there; 93% of the time they’re there until they’re proven they’re not there. Or you weigh risk versus benefit as I’ve talked about and then you move on. But you know you gave it a good try. Then when they’re there, you have to assume they’re separate until proven otherwise.

So Stropko – boy what a name... Stropko. Look at that name. I’d believe anything Stropko said. He said second maxillary molars; 60%. In the JOE, 60% had two MB systems in the second molar. Okay? So you thought we were talking about MB1s of maxillary first molars – and I am – but I just wanted you to have that idea because second systems live in MB roots of first and second molars.

Well I guess you’re getting a little discouraged because there’s so much work to do now. We could have a little higher fee maybe to give you time to find it. But let’s look at the ideas. You’ve seen this list before and I’m going to review it again. And I’m not going to say every word, because you know what? I’m showing you my lecture of 22 slides – hey some of you young doctors listen carefully. You think showing up at a lecture hall you’ve got to have like three or four hundred thousand slides. You’ve got to have boxes of carousels in the old days. You’ve got to have a laptop that has extra memory. You know what? Less is more. 22 slides and I’m going to show examples of every one of those except this one. And I hope you can imagine – close your eyes; everybody close your eyes and fantasize – I see myself training. I see myself with Dr. X. This one’s known very well. I see myself sculpting; sanding away roofs of secondary dentin. I get a catch with my explorer; I feel the ten files start; you’re already in the game. Get the training, okay? Get the training.

So there’s a lot of ideas. You’ve had time now to write every one down or take a picture. And we’ll start off with a little bit more ideas; radiographs, tomosynthesis. We’ve heard from Tyndall and we’re going to hear from Landwehr, but this technology is out there. Go to Portray. You have radiographs and many of you have CBCT – well a few of you have CBCT.

So on the straight on angle, you all know you’re going to see that. But if you learn to move your cone from straight on over to off axis, and let’s say greater – well maybe we should say this. Maybe we should say less than. Less than or equal to about 25-30°. Then you’re really making this root like my hand, and now that root will turn out looking quite fat. And as we come around to look at that shape and we start to see something over here with a handle on a file going in over here; and you’re going well geez. The distance from here to here is not equal to the distance from here. They’re not equal; that’s the rules of symmetry.

So this is what different views can show. I’m emphasizing three separate views. Tomosynthesis, you got a glimpse of it. It gives us an image stacked so you can get many different looks by going through the stacks. So you’re getting 7 ports that deliver radiation onto a plate, and so you’re getting different angles of the way those emanate and come out of the heads of the X-ray, so you’re going to get a very, very nice view. This is on the map; definitely we’ll be replacing this because it’s the same thing plus.

And then you have CBCT. I love CBCT because CBCT can give you the axial slice where you can say oh, I have something over here; but gee, I can see I’m not there. Versus you’d like to think you’re in something like that. Well then it’s pretty much centered, so you’re feeling comfortable that you’re within the root. These are just basic ideas.

So if you can see it, you can do it; how about that? Transillumination devices, overhead lights are nice, overhead microscopes are better, and altogether lighting and vision allows you to be at the top level of who you were designed to be. So you can push into a lot of these cases, you can see that lip we saw before, but what we have here is you know the canal is going to be back here. We’ve got to go this way. I don’t like to do it with a drill. You can take a fine tip diamond and just feather that lightly; that’s very efficient. It keeps the wall, the axial wall nice and flat. Light refracts off of a flat wall better than being dispersed off of an irregular shaped wall. So a diamond tip can be done, but a diamond tip goes in a handpiece and a handpiece has a big head, the handpiece. The head is obstructive and you’re always trying to see around it, right? Right? I know, I see; you’re always trying to see around your handpiece.

So learn to remove the bulky head of the handpiece. And you can do this with something that’s very small. The tips on these instruments are 10 times smaller than your smallest round burrs, okay? Now I know John Munce makes a corner longshank round burr, and probably I’m only about 2 times or maybe 3 times smaller – not 10 times – but a 2 round burr, 10 times bigger than the tip. So if you’re minimally invasive, you want to selectively do micro-instrumentation. And to the extent you use a microscope and ultrasonics, these are called microsonic instrumentation ideas.

And I want to get the arrow in. Did you see the arrow? Did anybody see the arrow? Gosh you didn’t even see the arrow. So there’s the arrow; you’re going to work at low power. Always work – regardless of the generator – this one is by Dentsply Sirona, Pro Ultra. Regardless, it doesn’t matter; use the lowest power that will accomplish the clinical task. So start at zero – it’s not working, or whatever you want to say to your assistant – bump it up a little bit. She goes one, and you just incrementally come up until the dust is sailing out of the tooth. You’re cutting, you can hear it, you can feel it, you can see it. It’s a marvelous day to be doing ultrasonics isn’t it? So you have different tips to do different things.

Here we are using a 1/2mm round ball. Just drag that ball along the groove, and just brush away that secondary lip of overlying dentin and boom, there it is; right in there is your payday. That’s what you’re looking for. The Stropko is used – I talked about the reference to the article; now I’m talking about Stropko, the reference to his product. Stropko invented this thing, I think in the ‘90s. It has been one of the biggest selling items internationally for scopers. But then general dentists’ that don’t scope discovered them, and said wow, what a tool! So you can have a Stropko adaptor go in a handpiece. You can luer-lock a variety of different cannula so it doesn’t blow off when you push down on the valve and air comes through here; you don’t want to shoot this across the room and put out your assistant’s eye. So we use this to collimate air to blow out the dust secondary to sanding. That means what? Continuous vision. Continuous vision. You’re never working in the dark.

I’ve talked for years about all this stuff. White-line Test? Well in necrotic teeth, putrescent teeth, as you use the ultrasonic bowl or the tip of an ultrasonic instrument, or feathered diamond, the biproduct is dust. Dust falls into anatomical space and it makes a white line. And you can actually track the white line, and it’s a roadmap that will lead you from MB1 to MB2. Okay, so that’s the white-line Test. And of course, if there’s a white-line test, why couldn’t there be a red-line test? Well bloody teeth are the other things we see, necrotic teeth and vital teeth. That’s the two baskets that come in. Well if it’s a bloody tooth and it’s bleeding, blood’s coming out of anatomical spaces.

So everybody saw a glimpse of the MB1. You’re getting a sense right here – wow; he’s showing us an MB2 that’s uninstrumented. But you might be saying what is this line here, coming of the DB that’s going off to about the middle of the pulpal floor? There’s DB1s and there’s DB2s; I didn’t show this case today. In fact this reminds me, if my team hears this, I’ll be showing another thing on – not MB2s certainly, or mid-mesials – but how about 4 and 5 and 6 canal teeth? They exist! I’ve got them. I’ve got libraries of them. So putting a file in the middle of a pulp chamber might not be your idea of success by design. But what if I told you there was a separate system in there that travels up about 22mm? Red-line Test.

And sometimes you open up teeth, especially failures, so they come back and they say it still hurts to hot. And nobody thinks a tooth that’s had a root canal would hurt to hot, until you find one that hurts to hot. All you have to do is isolate under a rubber dam and put hot water on it; and when they come out of the chair, you’ll go okay, there’s got to be tissue in there. So sometimes you can open these up, and when you dump sodium hypochlorite onto necrotic pulp tissue, you get a reaction. The biproduct is free oxygen, and you can sometimes see that emanating out of a canal; an MB2. So it’s a road map.

Okay, a little video and we’ll be done. It’s a bridge; it’s kind of got a club shaped root, kind of big. It’s got big diffuse lesions. So let’s take it on. You open it up and you’ve got your hole, so that’s where I’ll start, and here we go. The angle of the file is the angle you’re going to hold the handpiece. Everybody listen carefully. The angle the file goes in, that angle right there, that angle is the same angle of a GG1. You could do this a lot of different ways. Ruddle has done it a lot of different ways. I’m showing you a way, and it’s pretty low tech. You’re using a $1, GG#1. Notice how I’m arcing the shaft as I brush. Notice I’m doing a little brushing right here; a little brushing off to the buccal. A little brushing to the mesial buccal. A little brushing straight out of the canal; a little brushing to the palatal. You’re brushing. And as you brush, you’re selectively cutting on the belly of the GG; you have total control; the GG1 is .5mm. You know most orifices are going to end up around 1 or greater, so that’s very conservative. Watch the file drop in. Watch it drop in. Bam! Notice the file came in off axis, and just with a little idea; we upright the handle; it’s on axis.

So now we’re off to the other one. I’m sanding. Notice I don’t have any big, obstructive handpiece there. I have to look around it; I have total vision. So I can look right down a sleek instrument, I can selectively cut in a very micro way, and I can just chase along the groove. And I’m going to use 20, 25, 30 – not to length, not to length. Just wherever they go, turn a little bit, clockwise, counterclockwise, withdraw. Turn a little bit, clockwise, next file, next file, next file. Chip, chip, chip, chip; you’re starting to pre-shape. Maybe you can put an SX in there; maybe you’d put another rotary tool in there. But if you don’t have space, that’s how you break instruments.

So now I’m going to make the pathway a little better for my subsequent irrigation and obturation ideas, so take the diamond, the surgical length diamond – Dentsply Maillefer has the only long one in the world. And you can take the entire wall back, use the tip to selectively marry the axial wall to your orifice that you pre-flared with a series of hand files. And now you can just take a 1 or a 2 GG and bump, bump; make two snake eyes and you’re ready to clean and shape. You can irrigate, aspirate, irrigate, aspirate. You could spend $100,000 for GentleWave, you can use a 25¢ syringe, but you can put that in the MB.

Well quit getting upset with me all you guys out there about GentleWave. You have your technology; brag about it, OK? It’s just that not everybody’s going to have your toy.

So straightline access, zoom in. Notice that we’re clean; notice that we’ve got the interconnector clean. Just handheld irrigation. This was even before the age of what? The EndoActivator. Post-op film, we’ve got two systems. Look at that, two systems. Got anatomy. Notice how they flow and curve along their length. We’re in the business of treating canals, not making canals. MB2s are important. Systems define, especially in strategic teeth that are bridge abutments.

Last case... It’s that guy. Put the X in the right spot. That has had a DB root amp, that has had a palatal root amp. I saw that case in ’79; I had a 30-year recall on it. You would say no way Jose; look at the bone! Whoa, look at this. There’s nothing there. But let’s look at what Endo-Perio-Prosth can do. Endo-Perio-Prosth; notice how the bone has come up to the surface and filled in. And that’s a long, long term; two decades at least recall. So could have done an implant, but you also have some other ideas. And if you have other ideas to save teeth, be sure to find the MB2s.

Okay, so we’re going to close our show today with another influencer segment. And that’s where we talk about something that has really influenced our lives from a certain category. Today on our show we’ve already talked about a lot of things that influenced us. We’ve talked about motivational books, history, concepts that can influence you finding the MB2.

So yes, we decided we’re going to talk about technology for this close segment. And the reason we picked technology is because we were talking a lot when we were preparing our history segment about how much technology has changed in the last 75 years. So we thought okay; let’s talk about the technology that’s most impacted our lives.

Now I want to say right now, we’re not going to talk about like fundamental, necessary, basic technology like running water, toilets, electricity. Because I’m sure we’re all very grateful for those and they’ve really impacted our lives. But what do you think most people would say if you told them to pick one technology that’s really impacted their lives, what do you think most people are going to say?

I think it would be the smartphone. I think I see everybody in my walk of life – airports, other countries, janitors, construction workers, maids, everybody has a smartphone in their hand. Or they have it in their pocket; or they have it in their pickup truck. So I would have to think they couldn’t live without it.

Yeah, I definitely agree with that. It’s almost become a necessary thing for technology. So we’re not going to pick smartphones, and we’re not going to pick the other big stuff like running water and electricity. So what technology would you say besides those things has most impacted your life?

Medical technology was probably Scleral Buckle; you know band around the eye and then laze the Hell out of the retina to the back of the eye so you can see again. That was pretty cool. Lasik surgery, that was pretty cool because they can reshape your eye with a laser, not a scalpel, and then they can get the focus right back onto your retina, the deep part of your eye. So being able to see really well is good.

And probably outside of medical technology I would choose the laptop. For me the laptop is just a lecture machine. I don’t do any business on it; I don’t keep anything on it except maybe about 20,000 images. They’re categorized by different topics. They’re subcategorized within topics to subtopics, and I use that to make lectures and do the shows and stuff like that. So carrying a little laptop around is a lot different than – we’ve talked about the 4010 library, which is probably about as big as a VW, and it had racks that pulled out with 120 slides at a glance. And now where you had to pull racks out, well now I can just click little buttons and I can see things and have screens open. So I’d have to say for me, technically, it would be the laptop.

Okay. It’s interesting. When you brought up the Lasik thing, I hadn’t even originally thought of medical technology. But if I’m thinking about medical technology, I’m pretty grateful for the technology that repaired my ACL; I had my ACL repaired arthroscopically. And my knee was just completely dysfunctional, and then now it’s like new again. After I had my surgery, I went on and got my black belt in karate and I’ve never really felt held back by my knee at all.

So I guess if I was going to name one other technology – because you picked the laptop -

I picked my eye; you picked your knee.

Yeah. I guess I would probably say that early in my relationship with my husband, he got me a new stereo for my car and it has like the Bluetooth capability. And then I could all of a sudden get rid of all my CDs and I could just play songs from my phone in the car. And that was pretty exciting for me. I mean I actually would find myself going places in the car just so that I could listen to music.

Yeah, we had to put out all point bulletins for her, because she could just be aimlessly driving around listening to music.

Okay, well I guess probably a lot of people would pick television. I mean I think that entertainment is always interesting.

Well I guess if we did this segment 10 years from now, we would probably have to give another group of things that we would have to eliminate. We would probably have to say it can’t be anything AI.

Anyway, that’s our show for today. I hope you enjoyed it. And we’ll see you next time on The Ruddle Show.