AAE Endodontic Case Difficulty Assessment form and Guidelines as published by the AAE (www.aae.org)
Endodontic Diagnosis Assessing Case Difficulty & Clinical Findings
This episode opens with a discussion of why dentists are a good option to help with administering the COVID vaccine. Next, referencing an AAE form, Ruddle talks about the criteria to consider when assessing case difficulty. Continuing with the diagnosis theme, Ruddle then goes on to present various clinical findings and interprets their significance. Stay tuned for the close of the show with another new segment, “Ruddle One-Liners.” Learn the simple, yet powerful, phrases that dominate Ruddle’s thinking.
Show Content & Timecodes00:09 - INTRO: Dentistry & the COVID Vaccine 04:27 - SEGMENT 1: Assessing Case Difficulty 20:29 - SEGMENT 2: Clinical Findings 51:44 - CLOSE: Ruddle One-Liners
Extra content referenced within show:
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This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: Dentistry & the COVID Vaccine
[Music playing] Welcome to “The Ruddle Show”. I’m Lisette, and this is my dad, Cliff Ruddle. Are you ready to give our viewers a great show today?
I’m excited about it. Let’s go.
Okay. Well, we wanted to start off with some great news on – well, we think it’s great news. On Monday, January 4, Governor Gavin Newsome announced that dentists in California could now start administering the COVID-19 vaccine.
And actually, this was interesting to me, because a couple days prior to that, we had been talking about the slow roll-out of the vaccine, and you said, ‘Why aren’t dentists doing it?’, that they’re ideal candidates to administer the vaccine.
I believe that. When you go – when you think of a dental office, we’re already giving injections on a daily basis. So, we give anesthesia. So, it’s not a big deal to switch to giving a vaccine in the arm. Also, we have some trained Hygienists that have taken an anesthesiology course, and they’re trained to give injections as well. They could easily give a vaccination. And the third person that most people probably don’t think about is the retired dentist. I’m talking about people that are healthy, they’re vibrant, they have wonderful lives, they practiced for years or decades. And they still like to be feeling like they can make a difference for others. So, they still wanna golf, and they wanna do all those kinds of things, play with the grandkids. But they’d like to do something meaningful.
So, you have three kinds of people that could be summons to help out in this cause. The other great thing is, when you go to a dental office, you’re going into an environment that’s highly regulated. So, OSHA, for our international users, that’s the Occupational Safety and Health Administration, they have a lot of [laughs] hurdles we have to abide by, to be compliant. So, we’re OSHA. That’s probably as safe as any [laughs] hospital in the country. And then, the third thing is, we’re prepared to handle emergencies. And every year, the whole office has to be certified through OSHA to be able to handle all kinds of emergencies, including CPR.
So, we have the kits. We would have the ephedrine or the epinephrine that we could give, and it’s a clean office, with OSHA approved, and that could work. And we have reception rooms that are empty. So, we don’t want patients in there anymore. So, the reception rooms [laughs] around the country are empty. So, after the injection of the vaccine, they could sit in the reception room and be evaluated on their signs and symptoms, until it’s deemed they could get in the car and drive home.
Okay. Well, this announcement was made due to a Public Health Emergency Waiver. So, there are still a lot of details to be ironed out. Obviously, a lot of dental offices don’t have the kind of cold storage that the Pfizer vaccine requires, which is minus 94 degrees Fahrenheit. And then, the Moderna one needs to be stored at minus four degrees Fahrenheit. But then, once these vaccines come out of deep freeze, the Moderna vaccine will last up to 30 days in normal refrigerator conditions, and the Pfizer one can last up to 5 days. So, this does seem doable.
Mm-hmm. So, the clock’s ticking.
Yeah. But it seems like -- doable, especially if you have a list of patients that --
Well, you know how on another show we talked about how little things make a difference? There’s 180,000, roughly, dental offices in the United States. If everybody just gave 100 injections – it could be just to your own patients – then, we would have done 18 million vaccines. That would make a major difference.
It would, and I know a lot of the healthcare practitioners right now are really overwhelmed with treating sick COVID patients. So, this would help them a lot, too.
Absolutely. It would take away a lot of the pressure on our medical system.
Okay. Well, we have a really interesting show for you today, we think, and so, we’re gonna get started now. [Music playing]
SEGMENT 1: Assessing Case Difficulty
Okay. So, last week, when we were discussing who pays for treatment, if it fails, we touched on the idea of maybe not taking on a really challenging case, in the first place, if you aren’t experienced or qualified. So, today, we’re gonna talk about how to assess the difficulty of a case. And to do this, we wanted to refer you to the AAE Endodontic Case Difficulty Assessment Form and Guidelines, which can help in referral decision making and also documentation. So, on this form, various criteria are listed and then assigned a level of difficulty. So, we’re gonna talk about the criteria in just a moment, but first, why don’t you tell us how the AAE defines the levels of difficulty? I think it’s minimal, moderate, and high.
That’s correct. I have it here, and my eyes might even fall down occasionally to look. But the minimal difficulty is kind of an uncomplicated situation. Now, you’re probably thinking out there, ‘Oh, he’s talkin’ about the tooth and the root length, and all that.’ No, we’re talking about a whole cadre of things, like the patient’s health and all that. So, minimum difficulty, everything’s uncomplicated. And a competent – they say a competent [laughs] clinician, with minimal experience, can probably do it. And I was thinking, ‘If I was the patient, I wouldn’t want to know if they had minimal experience, and this was their third root canal, after dental school.’
So, I don’t know if I agree with that. Moderate difficulty would be considered complicated, and it would be considered, you have to be a good clinician, have great experience, and get these kinds of results pretty routinely. And I thought, ‘Okay. That’s fine.’ And then, it was [laughs] kind of interesting, when they got to the high difficulty, it was the most experienced clinicians, who have a long history of getting successful outcomes. And so, a lot of this turns out to be, you gotta look in the mirror, don’t you? And you gotta kinda be honest about it, you know, ‘Am I the best person qualified to be doin’ this?’
The high difficulty, it’s almost like they made it sound like maybe there’s only [laughs] a handful of dentists in the United States that might even [laughs] be able to do it. So [laughs] --
Well, yeah. I mean, if you want me to read it, ‘Predictable outcomes will be challenging [with emphasis], even for the most experienced practitioner, with a history of successful outcomes.’
[laughs] -- okay. So, on the form, various criteria are listed. And then, examples of given of different stages of difficulty. So, we’re going to start first with patient considerations, looking first a medical history. So, if I look at the form, I can see that no medical problems is minimal difficulty. One or two medical problems is moderate difficulty. And then, serious illness, complex medical history, disability, is under high difficulty. So, we’re not gonna break down each criteria in this way, but I just wanted to give you an idea of how the form is laid out.
It’s there. Yeah.
Yeah. So, can you talk to us some more now about some other patient considerations, like anesthesia, ability to open the mouth, emergency conditions, or if you wanna even go back to medical history?
Yeah. Medical history, I think you said it best, non-contributory, minimal. Moderate, they have two things or more, but controlled, like they’ve – on heart meds, hypertensive, that thing. And then, the third one, you already said. So, they’re very complicated. These are sick people. And so, you gotta decide if you wanna take them on. Anesthesia would be something every dentist has encountered. I mean, some people are very, very challenging to get anesthetized and get profound anesthesia. So, you add – you might ask a patient, chairside, ‘When you get anesthesia, do you normally get numb right away? Does everything work well?’ Patient say, ‘Yeah.’ Non-contributory, minimal difficulty.
Moderate is like, ‘Well, you know, I – sometimes the dentist has trouble getting this side number, down here.’ So, you might know that a block might be more problematic. And I’m not gonna go through, then, the really hard one, they never get numb. So, somebody says, ‘Yeah. I never – nobody can ever get me numb’, I’m referring them to Buchanan. All right. That was a joke.
Then, patient disposition, you have happy people, they’re cooperative. You have people that are not as cooperative, but moderate, they might just be really anxious. Well, we’re pretty good at removing anxiety and mitigating that, so they can have a peaceful experience that’s, in retrospect, not so bad. And then, of course, you can have people that are very agitated, they’re very difficult to work on, they have high expectations. And they have a long history of failed dentistry, where they’ve gone to this office, that office, and another office. Not that dentistry failed, but failure with relationships.
Another thing, can they open their mouth? If they can open like an alligator, minimal. Can open for a while, maybe the joint starts to get tired, and there can be some issues, moderate. And then, you can put one finger between their incisal edges, and they say, ‘That’s it!’ [laughs]
Well, that’s probably one – if you were a general dentist out there, you would probably say, ‘You know what? I’d sure love to treat that tooth. It looks like it’d be a fun one. But the aggravation’s not gonna be worth it.’ So, if you pick these things off, because you’re thinkin’ about it, it’s like a checklist in a cockpit of a plane. If you’re going through your panel, you’re gonna have a flight that’s successful. What else did you say? Reflex? Gagging? That kinda --
I guess, like emergency conditions, like there’s – some people might be in minimal pain.
-- oh, yeah. ‘I’m havin’ pain up here, it’s been goin’ on for about 50 years now, so I wanted you to look at it.’
But non-contributory, they have some pain, and you can find it quite a way. Harder would be like, they have pain, but it’s more diffuse, and it’s – and they don’t even know, sometimes, which arch it’s coming from. And so, then, there’s a bigger differential diagnostics, and more clinical, radiographic, and vital pulp testing things have to be done, to focus in and localize the problem. And I guess, in a really tough one -- what was it? They might come in, and they – they have severe pain and maybe swelling, maybe extraoral swelling, beyond the intraoral swelling, maybe a Ludwig’s or something. So, those are really sick people, and they’re even challenging for well-trained endodontics.
Okay. All right. So, then, the next category is diagnostic and treatment considerations. So, how would we assign levels of difficulty to diagnosis and radiographic issues?
You know, without lookin’ at the form a lot, just common sense, you look at the film, there’s a periapical lesion, there’s a lateral root lesion. You did your pulp testing, you did your clinical findings, and you – it’s straightforward. But you can imagine, if you looked at a radiograph, or a – for diagnostics, you can’t tell where the pain’s coming from, or you can’t even tell which quadrant it’s coming from, it’s really fine to say to a patient, ‘You know what? This is a tough one. It seems like it’s endodontics. It walks like endodontics. It smells like endodontics. Maybe we should get you to a professional, because they’re – they have more skills, and they’re more adept at these differential diagnoses, and you need help.’
Yeah. You probably might have an idea, if you can’t even tell what’s going on in the radiograph, that maybe the level of difficulty might be too high for your office.
Yeah. And then, of course, you’re talking about maybe looking at pathology, like lesions of endodontic origin. But we could also be looking – I’m kinda skippin’ around, but how long is this tooth? I mean, everybody out there knows that a 31-millimeter tooth is not the same as a 21-millimeter tooth. And so, how long is it? How curved do those roots look? And of course, the canals are more curved than the roots that hold them. And another thing you might look at is, you might say, ‘Well, gee, do I even see canals? Do I see a pulp chamber?’ So, look around at adjacent teeth, contralateral teeth, because you got a panel, and begin to say, ‘If there’s pulp chambers generally around the mouth, there’s probably a pulp chamber hidden under the casting.’
But if you don’t see canals even, or you see a big, fat canal that goes down to about mid-root, and it disappears, that’s a canal that you and I know divides, splits into two or more segments. So, just common sense. If – a problem recognized is a problem half solved, and if you start kinda going through this checklist that we’re talking about, you might catch a few of these and go, ‘I’m glad I got that out of the office.’
Yeah. I see that there – you’re talking a lot about morphology considerations, tooth morphology considerations as well as maybe where the teeth are in the mouth.
Oh, good. Yeah. Tooth morphology, and then, there’s this whole category on crown morphology. What if you’re going through the patient’s natural crown? Okay. They have an MOD something, composite amalgam, inlay. That’s completely different than I’m going through a porcelain fused to metal crown. Or how about this? I’m going through a casting, and it’s the terminal abutment on a five-unit bridge [laughs].
You might be [laughs] thinking, ‘Okay. I think I can do the endo, if I could get it out of the mouth and put it right here, on the bench, and I’m working like I did in the Ruddle course, a long time ago.’ Anyway, yeah. Crown morphology, root morphology --
-- resorptions come to mind. There’s internal resorptions, external resorptions. So, you really have to look at that radiographic survey. It’s not one angle. Get two or three angles, if you have a CBCT. That comes to mind. But begin to look for, where is the resorption? How extensive? And maybe in the axial slice, CBCT, you can see if it’s starting to invade and perforate externally or internally. Is it inside out, or is it outside in? Okay. So, internal, external resorption, sure. And all those things have degrees of difficulty.
I see also that they talk about how open the apex is. Is that, I guess, something that can make the case more difficult?
Yeah. I’ll say it – I just made this up, but if you have a terminus that’s about 60, 0.6 millimeters in diameter or less, so, less than or equal to 60, we can pretty much handle that with clean and shaping procedures. But when you start to get big terminuses and they’re over 100, they’re gonna have to think about a barrier technique. And not every dentist knows how to place a barrier so we can pack against it and control bleeding and overextension of our obturation materials, during obturation.
Okay. So, that’s the – their second category was diagnostic and treatment considerations. And the third category is just additional considerations. And I see they talk a little bit about trauma history.
Yeah. If a child is playing on the playground, psychodrama roleplay here. It could be anything you could imagine. And they catch a little elbow, or they’re swinging or bars or something, and two heads hit, and there’s a little incisal edge chip. That’s minimal. I mean, most dentists in the world can take and repair that with adhesion dentistry, and that’s something that’s in their wheelhouse. Maybe it fractured off and exposed the pulp. That’s probably, for me, minimal, because they’re used to doing root canals.
But if you start to see fractures that extend sub-crestal, root fractures, horizontal fractures, oblique fractures, mobility, artificial mobility compared to adjacent teeth, that’s complicated. And so, obviously, the difficulty goes up massively. You said, ‘open apex’. What if we have to do apexification procedures, to stimulate [inaudible] epithelial root sheath to elaborate more dentin, so that apex closes down? So, sometimes it’s good to get a second opinion on these.
Okay. I guess previous endodontic treatment is also something to consider.
Yeah. That’s my world. Over 90 percent of my practice, even in the last 15 years that I practiced, I was redoing other people’s work. Oftentimes the tooth had already had clean, shape, pack that failed. Oftentimes I saw patients come in, and they’d had retreatment by an endodontist, and it was still failing. And it was not unusual to see surgical failures. So, failures, just to say it quickly, when you see an endodontic failure, you’re dealing with a casting on the tooth, usually. There could be gutta-percha, silver points, carriers, paste fillers, okay? There could be blocks, ledges, transportations. There could be a metal post, a non-metal post. There could be a broken instrument, as just single examples.
So, when you start to see those in one scenario, or maybe you see two or three in one tooth, bye-bye. Get that case out of your office.
Yeah. Just to say something about that, they put minimal difficulty as no previous endodontic treatment. Moderate is previous, successful treatment. And then, everything else you describe would fall under [laughs] the high difficulty. So [laughs], maybe if there’s other things, like you were just listing, and you’re kind of a beginner, then, you would just wanna refer [laughs].
Yeah. And then, there’s endo-perio. I mean, that’s a category I’ve been heavily involved. In fact, just this morning, I was lookin’ at my phone, and I was lookin’ at the Endodontic Discussion Forum. It’s for AAE members. And there was a huge discussion. ‘Do we – Lisa, do we still do a root amp? Can we do a hemi-section? And does anybody have photographs? What’s the protocol?’ I have literally probably a few thousand cases, endo-perio. When I came to Santa [laughs] Barbara, in the ‘70s, it’s kind of interesting. All the periodontists were doin’ implants in the ‘70s. They were doing hemi-sections and root amps. They weren’t doin’ a lot of scaling and curettage procedures. Their bread and butter was, whack those roots off, split those teeth, and do quadrant surgery.
So, I saw so many roots swinging around in the breeze, with pulps hanging out of them, fresh out of the periodontal office. Sometimes they had dressing – a pack on them. Sometimes they didn’t. So, you get used to doing that. But endo-perio is a big category. It kinda went away with implants, and now, it’s kinda getting re-resurrected again, because implants aren’t 100 percent.
Okay. Well, we kinda just covered the whole form, and we’re gonna have this on our website, in our Show Notes, or, if we don’t have the form, a link to it. So, it’s – it looks like it’s a pretty helpful form to treatment plan.
You know, I’ve just read this form with you, and we’ve gone through it in our rehearsals. And I’ve decided to refer everything out. [laughs]
[laughs] But I – this actually kind of will – I know one thing you say a lot. You say, ‘Treatment plan for no surprises’. And that will kind of give you a little hint of what’s coming in our close of the show today, “The Ruddle One-Liners”. But yes, you do often say, ‘Treatment plan for no surprises’.
You know, I think, just to play off of you, ‘Treatment plan for no surprises’ is one of my major adages, because it’s fun, when you’ve anticipated things. And there’s always things in life that come up. That’s what grows the muscle, makes it stronger, so you can lift more weight the next time. So, don’t reject difficulties. Welcome them. But then, start to realize where your skill level is. And of course, as you grow, you can take on more cases, see? There – it’ll be right there. So, if you start to go through this, it’ll be a discipline that’ll make you look at your preoperative films and your clinical exam and your testing, and you’ll be in the game, without the surprises.
Yeah. And just one more thing. We talked about referring, if it seems too difficult. But this is great for documentation, too, like just documenting everything and having it in the patient’s file.
Oh. That’s a great point.
So, anyways, check out the form, and that’s the end of this segment. [Music playing]
SEGMENT 2: Clinical Findings
Today, we’re gonna continue our discussions on endodontic diagnostics. Recall in the past, we’ve talked already about the importance of the radiographic survey, three angles, different orientations horizontally. We’ve talked about CBCT. We’ve gone through vital pulp testing, and we’ve talked about the importance of that. But the third leg we’ll talk about today is clinical findings. So, it’s pretty interesting, as you practice over the years, you see people come in, you do the full-mouth exam, and what you start seeing, when you just look around.
So, today I’m gonna just show you some cases, it’ll go fairly quickly, but things that you can see, if you start looking. Some of these things, you might not have ever seen. Some of these things, you might’ve read about. But today I’ll show you, so you can see them again, or be reintroduced to something that might be a little bit interesting for you. So, here we go.
All right. So, the most important thing is to talk to our patients. If you must speak, ask a question. So, they’ll star to tell you a little bit about how they’re feeling, exactly, orally. You know, first you talk about the world and how they’re doing in that environment. And then, you get right down to the teeth. And so, when you start to ask about things, they’ll tell you what they’re noticing, what they’re feeling, their sensations, how long, et cetera. And what we need to do is just get in there and take a look.
So, it all just starts by lifting up that lip, and let’s look up into the vestibule. And of course, we can get that upper lip up, and we can look up into the fornix in the vestibule. You’re looking for anomalies, swellings, fistulas, sinus tracts, those kinds of things. And then, we can start goin’ around with a mirror, with looking at the teeth from the lingual, and we can begin to check and observe. And every now and then, you’ll see, wait a minute! This lateral incisor, this left, lateral, maxillary incisor look a little bit different. In fact, if you notice, it has quite an anomaly. That’s like an extra [sounds like] cusp. For $5, if you can tell me where the purulence [sounds like] is, I’ll send the check! But the first one, only.
Look! Right up in here! You can actually see a little purulence. You can take a Q-stick, it’s much smaller than your finger, and you can just press on that, and you can milk out a little purulence, and that’s an active and swelling. Now, you might ask yourself, ‘Okay. So, you see an anomaly in the mouth. What would it look like, radiographically?’ Well, we could just slide this over, and you can take a look. This is the cusp, you can see here, on the lingual. Over here, you can see that it’s a virgin tooth, but there’s these tracts. And this developmental anomaly means there’s going to be an invagination or tracts that microbes can crawl through, and they can enter into the pulp chamber and cause a complete necrosis.
And notice the big LEO, the big lesion of endodontic origin, not only mapping it apically, but you can see, there’s a big component of that lesion laterally. So, lesions form adjacent to the portals of exit. How I’m thinking is how I want you to begin thinking. You gotta start looking at this in terms, you would expect to see a communication from the canal proper, out to that LEO, and that lateral root lesion is fed by a portal of exit. So, that’s kind of this case. You’ll see these dens in dente. There’s different kinds. I’ll show you another one, a little bit later in the show.
Well, of course, you percuss teeth, and you tap gently. If they say that the tooth is exquisitely sore, they can hardly bring their teeth together, then you might just use your finger and push a little bit on a tooth. And they go, ‘Ah, that’s it!’ So, don’t be tapping on teeth, where they say it’s very, very acutely sore. You can use a Q-stick. I like a Q-stick, because it’s kinda soft, and it gives, and it has wood – a little wooden stick, underneath that cotton roll on the end. And you can place that around in the fissures, the central groove, and you can have them bite down and then, rock into work and balance. I don’t like the Tooth Slooth. It’s pretty hard plastic. It’s not like simulating out of the office experiences. So, I like the Q-stick.
Obviously, you wanna mark – use marking paper. You can check the nithology [sounds like], the bite, when they go into work and balance. And you can see, when you take the paper out, use your mouth mirror, and you can go, ‘Whoop! There it is!’ There’s a little anomaly there. That’s a prematurity. Palpation, get up in there with your finger, up in the vestibule, because these roots approximate the fornix of the vestibule, and if there’s endodontic lesions, inflammatory or infectious conditions, oftentimes they’ll break through the cortical plate. You can probe. You can probe. See the tissue blanch a little bit, two to three, two to three, two to three. I’m not too worried about a four.
But if you start to drop into a narrow defect that is deep, that could suggest a vertical root fracture, or it could be a necrotic pulp or failing root canal, where there’s drainage through the sulcus. Now, transillumination’s a big deal. Most dentist offices have them, everywhere in the world. But you can see, when you transilluminate, light will glow through that tooth. And if you come in with your wand, on the lingual, look at how it glows lingually, and it gets a little more faded out, a little darker towards the facial. But the light is glowing uniformly through the tooth.
Now, let’s look at what we might use. We have a box. This is Quality Aspirators, but there’s many – microscopes have ports that you can stick your wand into. But you can attach these fiberoptic lights to high-speed vacuum. This is high-speed vacuum, but it’s very small, very precise, for working in a tight spot. You can put them on curved tools. You can put them on elevators and retractors. So, they can be used across the range of endodontic treatment, from conventional treatment, non-surgical retreatment, to surgical treatment. And it brings a lot of extra light in.
So, back to this case, where we saw uniform light plane, lingual, buccal, let’s look. Come down the arch and do the next tooth. And that’s the diagnostics! The diagnostics is, we say that a fracture line breaks a beam of light. So, you can see, right here, we have good lighting to the lingual. The whole lingual cusp is alit, but if you look at the buccal cusp, it’s dark, the whole facial’s dark. That’s a tooth that has a crack. Okay? So, fiberoptic lights are very, very useful to determine extent and the level of the fracture and the propagation line itself.
You can go on and do another tooth. But now, we can start looking at mobility, start wiggling these teeth. You know, when there’s a lot of infection, these teeth can be elevated in the socket. They can become quite mobile and loose. I remember many times over the years, teeth that were depressible, could tighten up after clean and shaping, to like a-half- to one-millimeter mobility. So, you can have tremendous knowledge, just by is a tooth looser than an adjacent tooth, an opposing tooth, or contralateral teeth? And I’m assuming in non-periodontally involved mouths.
Okay. We’re all good on the marker. Keep going. When you’re doing your clinical exam, of course you wanna get to know what people – how they – their teeth come together. That’s the bite, the nithology, if you will. We want them to go into the working and balancing and protrusing. Those extrusions will tell you a lot about prematurities, teeth that are maybe sore because they’re getting beat to death on certain excursions. So, be sure to look at the mouth very carefully and have them go through the three motions, work, balance, and protrusive excursions.
Well, what else? You gotta look at the margins. A lot of these teeth get heavily restored over the years, and you’re always wanting to anticipate, how is the soft tissue responding to the restorative? Is there any allergenicities, or are the margins just not appropriate? They don’t fit. The [laughs] – they don’t fit the impression, the tooth model that you prepared, well. So, you can pick up a lot, if there’s erythematous tissue, edematous tissue, pocket, bleeding. All these things are an indication, how the body’s responding to your work.
When you see that little indentation, right here, not this lecture, but that’s a tip-off. Because if you think about maxillary bicuspids, in fact, on the Endodontic Forum this morning, there was a big concern, because somebody found a three-rooted maxillary bicuspid! So, I told my daughter, ‘We’ll show like about 50 of them, so you can see that we [laughs] find them, and they’re there.’ But there’s tip-offs, with your probe. You can even feel the little furca, the little furca. And then, you can keep probing. So, those are ideas that can help you understand your radiograph better, and you can marry all of those ideas to your vital pulp testing. Your pulp testing, might be vital, might be necrotic.
You know, there’s a lot of trauma, and there’s a lot of injuries. And so, when you see the classic, dark tooth, the classic, dark tooth, that tooth is a tooth that has probably got a necrotic pulp. A lot of times, when these teeth get hit hard, you can break a vessel or, in this case, a capillary or an arterial, on that level, and that bleeding can get out into the tubules, and that can stain. And that’s called the bilirubin, that kinda stain, where that blood gets out in those tubules, it’s away from circulation. It begins to dark and discolor. And now, the translucent enamel, you’re looking through, and you see the classic, dark tooth. So, this would be a tooth you’d definitely wanna take an x-ray of, to see what’s going on.
Are you havin’ fun yet, with all this clinical findings? I mean, we get so used to lift up the lip, under the tongue, look in the oral ferrics. We’re really fast, but there’s stuff to find for the thoughtful clinician who’s doing a diagnostic mission. All right? So, now, we’ll go ahead and look at some more. Today, I’m going to do something that I have never done in all the years I’ve been teaching, and I’ve been teaching for about 45 years and been in endodontics for about 48 or 49 years. This is gonna be new for some of you, even as endodontists.
The question is, where are the five places, the five geographical areas, where we can find a periolis [sounds like] or a sinus tract? How about that? Five! So, we’re gonna go public. We’re gonna find five different locations! And in these locations, we’re gonna be able to start to identify what happens when pulps break down. Well, the egress is out of the root canal system, and of course, the bone starts to get destroyed as a response to that injury, emanating from the root canal space. And all of a sudden, you can have fissures that go out and land in the attached gingiva. So, number one, attached gingiva. I don’t wanna write all of these out. Attached gingiva. Okay? That’s one place.
Well, we can look around the mouths, and we can see, whoa! What’s that?! Well, this is a stab at conventional treatment. When that failed, it was referred to an endodontist, who did an apicoectomy on two teeth. This one seems to have worked, as evidenced by, we don’t really have a lot of apical pathology, but the sinus tract, here, is going to that central incisor that’s failing endodontically. It’s leaking. And this – this one is where? It’s in the lining mucosa. Probably you can see a different pen better, but anyway, a lining mucosa. That’s a second place. So, we can find them in this zone, and we can find them in the lining mucosa. Attached gingiva, lining mucosa.
Where else do we find those elusive – oh! Well, this is kind of a combo. It’s kind of at the muco-gingival junction. But what’s astounding about this is, you can trace it – you know, take a gutta-percha cone, trim off the spindly end that’s gonna bend and collapse on you, and then, say to the patient, ‘You have a little bump on the gum. You’re – you have draining infection. I can take this little cone’ – show them, ‘And I can put it in there, and I can slide it through very carefully and slowly, and I think you’re gonna be just fine without anesthetic. In fact, I’m gonna put you in charge! If I exceed your comfort zone’ – don’t say ‘If you feel anything’, they’ll feel it. ‘If I exceed your comfort zone, just raise your hand, and I’ll stop.’
The gutta-percha and only three degrees elevation of temperature becomes very flexible. We know that from obturation! You know, body temperature’s 37. Gutta-percha becomes moldable at 40. So, we don’t have to do too much. We can slide it in there and trace it, and then, take the film. Have the patient already draped. Have the cone right there. So, you go, okay. Get the film. They’re already draped. You don’t have to start, ‘Where’s the lead blanket!? Where’s the lead blanket!?’ Okay. So, you’re ready to go.
What is amazing, and you know this, but silver points, which were taught in the ‘30s, in the United States, they were the universal obturation. Thousands and thousands of dentists learned to place the silver points. Millions of patients received them. And of course, it took a few years, and the failures started coming back to roost. And these silver points, they corrode. And when they corrode, those corrosion products can leak through the sinus tract, and it can tattoo – because some people will come in and say, ‘We have a familial history. There’s melanoma in the family! I had a melanoma!’ And what you tell them is, ‘No. Rest assured, you just need to have retreatment.’
Okay. Where else do we find these sinus tracts, these periolises? They can be through the sulcus. They can be right through the sulcus. Okay? And so, every tooth must be carefully probed. You can do it with or without anesthesia. Obviously, dominantly, we do it without anesthesia. They’re patients, they’re in for an examination. You don’t necessarily give them. But on the next visit, if you’re gonna go to work on that same patient, in that same condition, too, then, after anesthesia, you can re-probe the case. And now, you can probe a little bit more vigorously, and you’ll, a lot of times, uncover a pocket that you never picked up when you were trying to be careful and kind to the patient, during the examination.
So, if you probe all around teeth, and don’t just probe a tooth. Probe – spot check one here, one here, one here, jump down. All of a sudden, do the one that you’re thinkin’ might be a problem. In this case, this is a mandibular, left molar. Probe it. We have another view. This is not very excellent endodontics. It’s mediocre endodontics. Very, very questionable shape. So, things that don’t look right a lot of times aren’t right. Things that don’t look right a lot of times fail. When there’s failure, there are lesions, and those lesions oftentimes show themselves. They reveal themselves as a pocket.
So, when you probe this one, you can see the perio probe is probed. I mean, this probe has 3, 6, 9, 12, 15. You can see we’re right to the 15-millimeter level. We got that thing buried! That probe’s going down probably somewhere around this level, right through the sulcus, which is up in here, boom! Right down into there. So, that’s a narrow defect. If you lift this up and move over, come down the lingual a little bit, two, three, two, three, two, three. If you come around the wide angle, and come towards the contact, two, three, two, three, two, three. So, that is a narrow defect. And of course, the differential diagnosis is [pause] – vertical fracture, failing endodontics.
Now, we talked about assessment, the Endodontic Assessment Form. And you could be thinking about that assessment form, and the discussions I had with Lisette, and apply them to every single case you’re seeing. And I may be a little slow, trying to bring that back in, but to tie it back in, that segment will get you familiar. Because as you look at things, you may go, ‘You know, I depress tongues. I look in oral pharynxes, all day long. I’m looking for drainage.’ Because 20 percent of all sinusitis is odontogenic in origin. So, I know if I depress tongue, and I see purulence in the oral pharynx, that’s not very healthy! It could be allergenicity, maybe. But it also could be that there’s a massive [with great emphasis] lesion, and it breaks into the antrum [sounds like].
So, on an assessment form, you may say, ‘Well, it’s not a back tooth that’s too far back. It’s just a bicuspid, Cliff. It’s just a second bicuspid! I can get there!’ Okay. Great! You gotta go through a crown. Remember, we said a virgin’s tooth’s easier, because there’s better orientation. You could go through a casting. A PFM’s gonna be harder than gold, okay? So, look at the – how the tooth’s restored. Those tooth-colored restoratives, you can go through a few diamonds and burs, getting in through the metal, into the tooth. So, now, you got that handled. And let’s say you did that. ‘Well’, you think, ‘you know, I have been around the block a couple times. I know how to get gutta-percha out!’
Is it gutta-percha? Is it a paste, or is it gutta-percha? Well, listen. Why do you think the lesion is all the way along the root? You must be aware that there could be lateral canals that are disseminating irritants. There could be lateral canals that irritants are coming out. Okay? You might think, ‘You know, it’s short. I wonder why it’s short.’ Sometimes when a case is short, it’s just short, and a file goes right to length. Yeah? Sometimes it’s blocked! Sometimes it’s ledged! Because sometimes people take a canal that looks like this, and then, they prepare it like this, and make a seat.
We talked in another show about making that seat. And all of a sudden, debris gets up into this area, and all of a sudden, you’re thinking, ‘Oh, I can get the gutta-percha out! That’s real easy.’ But can you get through the rest of the canal, to get to the terminus, so you can be definitive? So, that might be a case that you might wanna refer. Just might be [laughs] a case you might wanna refer. See, this is my world. This is what comes in to see Cliff Ruddle. So, history of endodontics, by an endodontist. Look, I don’t care who’s doin’ the cases and who’s doin’ the treatment. If you have, what? Training, experience, and relevant technology, you can grow into a lot of cases, and that could be for a well-trained general dentist.
We talked about earlier, in this very show, desire. Do you love doin’ it? Is it fun? People don’t care how much you know, until they know how much you care, that kinda stuff. So, what’s this?! Oh, my gosh! It came right out of there! So, when the surgeon placed the retro, it wasn’t even at the end of the root, ch, ch, ch. That’s the end of the root, down there. Threw it in the side of the root, prayed! Really got down and said some prayers, I’m sure, lots of praying! Hail Mary’s and stuff. But within about a year, because of leakage, it fell out, and now, it’s laying way [with emphasis] down in that osseous defect. This is a massive lesion!
You probably didn’t see this, when the patient walked in the door. What you probably saw, when the patient walked in the front door, was [pause] – this. This is another [with emphasis] place! Attached gingiva, lining mucosa, through the sulcus, into the sinus! And now, extraoral. So, this patient has quite a periolis. That’s okay. That can be taken care of. We’re very good at resolving this kinda stuff. All this – I’ll show the case later. I’m gonna be getting – I’ve had requests from around the world, ‘Please, a little surgery. A little surgery for us!’ We have lots of surgery [laughs].
I was at ground basement zero, when we were getting away from, you know, what? Loupes to microscopes, from round bur slow speeds to ultrasonics, CRIP control, hemostatics, flap design, going to medical to find the scalpels and the retractors and the elevators that were much more scaled for what we were doing. So, this patient, she didn’t go to the dentist. This was certainly a problem that wasn’t dentistry in origin. She went to the dermatologist, who made an incision, made an incision, you can see it, right in here. And that incision was so they could take a biopsy. So, that patient then went off, and the dentist – or the physician was going to find out what the bugs were.
Well, you know what? He put her on massive antibiotics. It closed down and revisited, six months later, and he made another, secondary incision. And now, we got a scar. Now, we have a facial scar, and it was something as simple as a tooth problem. So, by the time the case gets to me, this is my diagnostic information. So, if I’m going back to that [laughs] assessment form, I’m thinking, ‘Well, I don’t normally see fistulous tracts and sinus tracts extraoral. Maybe I should think that one might need a little more skill than I have.’ And then, I take my film, and I’m going, ‘Oh, my goodness, we’re gonna probably have to go in here and retrieve this, clean up these roots. I think we’ll have to [inaudible] – is this okay? Is that okay? Is it really just that guy?’
So, that’s something where I want some help. So, treatment plan for no surprises. Get it to somebody who does it all the time. You’ll look amazing! Okay. Now that we’ve noticed where the five locations are, where we can find a fistulous tract or a periolis, or a sinus tract, let’s go ahead and look at what else we might see. Now, I showed this case under a Traumatic Episode segment, when we did the Andreasen tribute, and I don’t know that we need to say any more than, when you look at people, you look for symmetry. And when you look at this young lady, you don’t see symmetry. You see a lot of swelling under the orbit of the eye, in the nasolabial fold area. This is all full, in here. And she just came out of the hospital, but her lip was all swollen, about two or three days earlier. So, massive antibiotics, and it got her under control.
So, you see extraoral swellings. We see intraoral swellings. You see these a lot, and you just have to roll up your sleeves and take the film, find out what the culprit is. But what you’re noticing, over and over and over, lesions are asymmetrical. That means there’s expected anatomy. There’s a missed canal. This is the life you live, when you go into non-surgical retreatment. So, that’s causing all that swelling. Intraoral swellings, intraoral swellings related to endo-perio, remember we had other patient considerations in that endodontic assessment form? It was like trauma, endo-perio. It was things like that. Well, is it endo in etiology, or is it a periodontal lesion, masquerading as a lesion of periodontal origin, when in fact it’s a lesion of endodontic origin.
These are all things you have to do with your endodontic exam. Clinical findings, pulp testing, and what else? Films. Take your films. And of course, you can look at these cases, and you start to do that mobility test. Remember we talked about mobility, just a couple minutes ago? Well, this crown, the patient says, ‘It’s loose. It’s loose.’ Well, of course it’s loose, because the crown could’ve lost its loading [sounds like] agent. That could’ve been rendered useless. Seals break, cement fails. But oftentimes it can also be related to fractures. So, now, you gotta start to assess the level of that oblique fracture. And all these have been treated in another lecture. We’ll show you the treatment of all these clinical findings.
This is just my initial clinical findings. So, interesting stuff. You got good zone of attached gingiva here, so it just depends on how far that probes and how that little segment piece, how it shears off, up apical on the root. Let’s go, again, forward, and I think if you look carefully at this case, if you look really carefully, this one is about plus four millimeters, if you look at this dimension, as compared to if you look at this dimension. So, incisals are – they’re just about equal in their mesial distal dimensions. So, when you see something that’s a little bit bigger, it makes you wonder, ‘Well, why is there an anomaly on that crown?’
Remember, the AAE Assessment Form, where they talked about crown morphology. Well, that’s what this looks like, if you look at the radiograph. And we’ve looked at this case before. But we haven’t really focused on this and the clinical findings. That’s another dens in dente. So, you saw one up on a lateral incisor. In the United States, we call the maxillary left, a 10, number 10. Well, now, you’re seeing it on number eight. And this is another one with virgin egress of bacteria into these tracts, gets in, internal resorption, massive lesion. Okay? So, that’s that one. And you can see right in here, where we have bacterial tracts.
I guess that would be a good glimpse of different anomalies you’re gonna see in everyday practice. I haven’t shown you everything I’ve seen. You would have to have maybe a couple hours on this, but this is most bread-and-butter things that you’ll see when you just lift up the lips and start doin’ your clinical exam. So, do your clinical exams. Learn a lot from them, and remember, the exam will tip you off on where you wanna focus your x-rays and how many angles you want. You might want your CBCT shot. You might wanna have that survey in there. But altogether, you’re gonna be able to treatment plan for no surprises. [Music playing]
CLOSE: Ruddle One-Liners
So, we’re gonna close our show today with a new segment called “Ruddle One-Liners”. And is – what that is, is – is, my dad often says these things, like, a lot, and they kinda stick with you. When he lectures, he sometimes says the little phrases over and over again, for repetition, and people remember them. So, a lot of people know you by these quotes. Some of them are quotes. Sometimes it’s lyrics from a song. Sometimes it’s just stuff you made up. So, I’m gonna say some of your one-liners, and then, you can tell us maybe where you got it, what it means to you, or that kinda thing.
Perfect. Go ahead.
Okay? And we’ll just get through as many as we can, in about three, four, five minutes. Okay. So, here’s the first one. ‘Nobody cares how much you know, until they know how much you care.’
Well, when I first got out of Harvard, and I probably was in my first week of practice, I looked kinda young, and people wondered if I was an assistant or an auxiliary in the office. And so, you need to talk to people. And when I realized I was maybe getting too technical and explaining things in too much depth, they didn’t care about all of that. What they cared about is that I cared [laughs] about them. So, I always wanted to make people feel comfortable. And by doing that, you ask questions. If you must speak, you ask a question, because then, if I ask you a question, ‘How are you doin’ today, Lisa?’
Have you ever had a root canal, before?
You’re not afraid to pay the bill, are you? [laughs]
So, anyway, you ask questions, and you get people talking. See, we laughed a little bit. So, that’s what you wanna do. And then, people realize you care about them, and they realize that you might be technically trained, and you might’ve gone to this school, that school, but they realize you care.
Yeah. And not only care about them, but also just care about your topic, like how passionate you are about it. Because when I hear you talking about something that I might not be that interested in, but I can see how interested and passionate you are about it, it makes me more interested.
Yeah. I think – I think that’s a good point, is you have to – I don’t know if you have to love your work. But if you’re blessed to do something that you love to do, there’s hard days, there’s easy days, there’s beautiful days, there’s horrible days, but altogether, it’s fabulous.
Okay. I’m gonna say some – something you say now, all the time when you lecture. ‘Brush, float, follow’.
Oh, okay. Well, that was a ProTaper thing. So, our team, Pierre and John West – Pierre Machtou, Professor Machtou, they saw them on another season. But anyway, these guys, we were trying to describe and paint pictures in our minds, because when you teach, most everything’s forgotten. So, people leave the room, and they forget everything. So, if you can just have them like a little song or a little saying that sticks, then, I want them to know I’m on their shoulder, in their next clinical day, when they’re takin’ a ProTaper shaper into the canal, I don’t want them to be pecking. I want them to – give me a piece of paper. Tear out a piece of paper. You have – oh, you can’t tear out a piece of paper.
[laughs] I don’t wanna lose [laughs] --
Oh, I can’t do this joke. Never mind.
-- okay [laughs].
I like to take a – I actually stand on a chair, to make a bigger impression, because I’m very short.
And so, I would take a – I’d say to somebody in the front row, ‘Give me a piece of paper.’ And they’d give me, and I’d wad it up into a tight roll, but I kinda open it up. And then, I would drop it, and it would go [sounds like a plane], it would float to the ground. That’s how you float into a canal. You don’t push files! You don’t peck, peck, peck! You – like a snowflake, you float in. And you follow the glide path. And of course, when you meet a little bit of resistance, brush, brush! Brush on the outstroke! Brush away from furcal danger! Brush to the greatest dimensions! And when you start to float, follow, and brush, all of a sudden, it’s a different experience. You’re using the same file, but the file is now beautifully following your mental command.
We’ve actually had course attendees that have come back to us, and they’ve said that while they’re doing a case, they actually hear you [laughs] in their head, saying that phrase. [laughs]
They’re supposed to hear me! My gosh, I’m the teacher.
Okay. Maybe one more. ‘The teacher shows up, when the student is ready to learn.’
Well, I failed high school, literally. I mean, they waved me through, because --
-- you can’t have a 40-year guy in high school. So, I went to college, and I realized I didn’t have any of my prerequisites for any of the classes I wanted to take. So, what I found in high school, I was all into sports and young women. That was the thing. And I didn’t care about things, and I didn’t do well in school. But you know, I went to college, and I was taking this math class, and I just got – I just loved this math teacher! And he was so smart, and he could explain things. So, I became engaged. So, the teacher showed up, when Ruddle was actually becoming ready, mentally, to sit down, surrender, and learn. [Music playing]
Okay. Great. I love those. I love those things you say. Okay. So, that’s our show for today. See you next time, on “The Ruddle Show”.
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The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.