Controversy… or Not Is the Endodontic Triad Dead or Stuck on Semantics?

This show opens with Ruddle and Lisette identifying some of the extraordinary challenges facing dentists in 2021. Next, Ruddle dives into some controversy and confronts it head on: Is the Endodontic Triad dead? Ruddle gives clarity regarding specific claims made by those who propose the triad is outdated and irrelevant. And finally, the show closes with the spotlight on the other Ruddle, Phyllis Ruddle – aka The Animal Whisperer – in another installment of “What Phyllis Thinks.”

Show Content & Timecodes


00:09 - INTRO: Challenges in Dentistry 2021
07:08 - MAIN SEGMENT: Controversy – The Endodontic Triad
33:59 - CLOSE: What Does Phyllis Think?

Extra content referenced within show:

  • Clark C: What is the Average Dental School Debt? NerdWallet, 7 September 2021, https://www.nerdwallet.com/article/loans/student-loans/average-dental-school-debt
  • Ruddle CJ: The Endodontic Triad: The Role of Minimally Invasive Technology, Dentistry Today 34:5, pp. 76-80, May 2015 (see downloadable PDF below)
  • AAE Discussion Open Forum: https://connection.aae.org/communities/community-home
  • Khademi JA, et al: Image-Guided Endodontics: The Role of the Endodontic Triad, Dentistry Today 35:8, pp. 94-100, Aug 2016
  • West JD: The Endodontic Triad: ‘Dead or Alive?’ Dentistry Today, 1 April 2021, https://www.dentistrytoday.com/the-endodontic-triad-dead-or-alive/
  • Ruddle CJ: Foreword I. In Lasers in Endodontics: Scientific Background and Clinical Applications, Olivi G, De Moor R, DiVito E, eds. Springer International Publishing, pp. v-vi, 2016
  • Ruddle CJ: Endodontic Controversies: Structural & Technological Insights, Dentistry Today 36:10, pp. 120-124, October 2017 (see downloadable PDF below)


  • Select PDF content displayed below. See Ruddle's complete library of downloadable PDF content at www.endoruddle.com/pdfs

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    Downloadable PDFs & Related Materials

    Ruddle Article
    “Endodontic Triad for Success”
    May 2015

    For more than 50 years there has been universal agreement that the triad for endodontic success is shaping canals, cleaning in 3 dimensions, and filling root canal systems. Further, it is globally accepted that 3D disinfection is central to success and has traditionally required a well-shaped canal...

    Ruddle Article
    "Endodontic Controversies: Structural & Technological Insights"
    Oct 2017

    Since the beginning of endodontics, every decade has witnessed controversy. Currently, there is ongoing debate regarding the concept of minimally invasive endodontics (MIE) as it clinically relates to preparing any given access cavity or canal...

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    Disclaimer

    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: Challenges in Dentistry 2021

    Lisette

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

    Cliff

    How are you doing?

    Lisette

    I’m doing pretty good, but you didn’t answer me.

    Cliff

    I’m always doing excellent. Thank you.

    Lisette

    Okay. Well dentistry, like all medical professions, faces constant change. New technologies are always coming to market. Techniques are evolving and being refined, and dentists feel a lot of pressure to feel on the leading edge of this change in order to be competitive. And also, the challenges themselves that dentists face change year to year. So, we have a list, and let’s see it. The challenges that dentistry is facing in 2021, the biggest challenges, and we’re just going to go over the list really quickly, because I actually thought it was a pretty interesting list. So, the first one is COVID-19 pandemic.

    Cliff

    Well, we’ve had a lot of shows and actually segments and special reports on this, so I won’t go through it again because dentists are acutely aware, they’re acutely aware of all the challenges and the scheduling issues ands the PPEs and all that stuff, so yeah, that’s on their mind. It’s stressful.

    Lisette

    Yes, and but I do want to add that dentists have done actually very well at, you know, handling things. I’ve been to the dentist a couple of times, and I’ve been very impressed with my dentist’s office that I’ve been to.

    Cliff

    As much as any profession, dentistry has been there in the early parts of 2020 and we did the triage, handled it beautifully, but lots of adjustments.

    Lisette

    Okay, number two is financial, and that includes both student loan debt and the cost of running a private practice.

    Cliff

    Well alarmingly, dentists in the United States, when they graduate from dental school, they are on average $304,000 in debt, $304,000. So that’s going to be stressful potentially, but then if you go on and specialize, we can look at ortho as an example, and that’s double and that was $617,000 in debt, so you’re starting off before you see your first patient with a lot of debt. So, on other shows, maybe we can cover that and how to start managing that. That’s a background conversation that affects all conversations that create all action plans.

    Lisette

    Just you saying those numbers gives me a little bit of stress. I can’t imagine that.

    Cliff

    So, when you get out of school and maybe don’t open up the Taj Mahal, maybe be an associate, go to a GPR program, do an advanced educational graduate dentistry program, DSOs, public health, all these are ways that you can start learning more about the craft, making a little bit of income, but not incurring a lot more debt.

    Lisette

    Yeah, we did talk about DSOs on our show when we interviewed Gary Glassman, so that – you can refer to that if you want. Okay, number three, finding new patients.

    Cliff

    Well, you find new patients like you always found new patients. They’re not necessarily under every rock, so treat people well and people will come back. So, you must also close with your patients and ask, you know, you’re not thinking about asking for a referral, but they don’t realize you wouldn’t be there in the future if there weren’t patients to get you through the interim. So, how you guarantee you’re there in the future for the patient is by being busy. So, ask your patients for referrals.

    Lisette

    Yeah, and I think we talked about in our show we did on practice culture, we talked about that probably if you have a good practice culture, over 50 percent of your new patients are just from word of mouth from your existing patients.

    Cliff

    Oh yeah.

    Lisette

    For a general dentist.

    Cliff

    Yeah, that’s absolutely so important.

    Lisette

    Okay, the fourth thing is time management.

    Cliff

    Well, the first thing that comes to mind is scheduling. When we don’t have as many patients per day and we have to keep our reception rooms more vacant, then when we get somebody in there, let’s do the consultation and let’s treatment plan for no surprises, and let’s schedule the time to not only do the root canal, if you’re Cliff Ruddle, but let’s get the buildup done and get it back to the general dentist. Schedule so you can do the post, the core, the buildup, and take an impression and provisionalize. Let’s do more work in that time. We’ve done other segments where we’ve talked about how costly it is to reschedule that patient.

    Lisette

    Right. And then also maybe time management in terms of just, you know, scheduling time for family and recreation as well as work, so that’s also balanced.

    Cliff

    Yeah, got to get the balance in there. That’s a good point. Stretch, do the yoga, do the running on the beach, do all the things that give you juice so you’re back in there and you can handle and manage the stress.

    Lisette

    Okay, the next thing, competition, staying ahead of the competition.

    Cliff

    Oh, come on, welcome competition. Competition isn’t good or bad. It just is. If there were no competition, you wouldn’t even exist. So, welcome the competition and then just get better. And how you get better is train, get role models, get your staff trained up, have fun, and be as effective as you can be.

    Lisette

    Okay. And the last item on the list is health issues.

    Cliff

    Oh, health issues, okay, so dentistry has been known to have a few health issues. But in essence, if you just get out of the office, clear your mind, family, grandkids, children, sports, exercise, all these things refresh, rejuvenate and recharge so that when we get back in there, we can handle the stress.

    Lisette

    Right, and then also I guess dentists tend to have maybe more back problems from, you know, sitting all day long, so there’s actual physical and, you know, stress, and mental health problems too. Dentistry is actually one of the most suicidal of the medical professions. So, don’t let it get to that point. Okay, well it does seem very challenging to be a dentist right now. Do you have any encouraging words?

    Cliff

    Confucius.

    Lisette

    Okay.

    Cliff

    Confucius. I have it right here. Wouldn’t you know it’s right here. “The gem cannot be polished without friction, nor man perfected without trials.” So, welcome every trial. It’s part of who you are. It’s part of the journey. And every time you overcome a little trial and tribulation, you get a little bit better. It’s like a muscle. Keep working it. Exercise it. Get strong.

    Lisette

    Okay, sounds good. All right, we have a great show for you today, and we’re going to get going on it right now.

    MAIN SEGMENT: Controversy – The Endodontic Triad

    Lisette

    Okay, so for more than 50 years there’s been universal agreement that the endodontic triad for success is shaping canals, cleaning in three dimensions, and filling root canal systems. There’s also been majority consensus that the leading cause for endodontic failure is not reducing the bacterial load enough. So, for many of you I just stated the obvious, however, about a decade ago a group of clinicians came forward promoting the idea that the endodontic triad is dead, outdated, and irrelevant.

    So, we have published articles disputing this idea and addressing it. You’ve lectured about it. This really is nothing new for us, but recently you read something on the AAE discussion forum that brought this triad controversy to the forefront of our minds again. So, today, we thought we would devote this segment to talking about it a little bit. So, what did you read on the AAE discussion forum that kind of got you going again on it?

    Cliff

    Well, that in itself would probably blow our timeline, but I scan it every day to look at the discussion forum. It’s 24/7, so it goes all the time. And I’m always looking for what people are talking about and what’s hot and what’s not. And so, there was this whole discussion about something completely unrelated, and out of it, there was this quote from Herbranson, and so he comes on and he says that the shaping has been de-coupled from the so-called triad and it’s not anymore a triad. So, that was interesting.

    And there was a couple other things I’ll just throw out, because it seems like there’s rarely evidence on this discussion forum, and there’s a lot of clinical cases presented, where they show lateral anatomy for pulp canals, lateral canals, apical bifidities, loops, deltas, anastomosing. So, it’s rare, but when they do, it’s almost like they run the flag up, because something’s been done that’s never been done, and the words are usually, “Did you wave it?” “Oh, that was Gentle Wave case. Oh, he must have waved it.”

    So, there’s like no recognition that thousands of clinicians get lateral canals every single day without this technology. So, when I saw his quote, that’s what got me thinking how can he decouple something that is fundamental to let us move our reagents, no matter how you do it, and then to fill root canal systems, no matter how you do it. So, that was what got it all started.

    Lisette

    Okay, well one of the first articles that I’m aware of that promotes this idea that the endodontic triad is outdated and irrelevant is – it was published in Dentistry Today, 2016, called Image-Guided Endodontics: The Role of the Endodontic Triad. And the lead author is Dr. John Khademi. And I think the best way to approach this is for me maybe – to have me read a few quotes from the article, and then you can address those claims.

    Cliff

    Are you serious?

    Lisette

    I think this is the best way to do it, and I’ll explain why actually maybe a little later. But are you ready?

    Cliff

    I’m ready.

    Lisette

    Okay. So, here’s the first one. “Protocols have been based on the tooth type, not specifically tailored, nor executed in appreciation of the morphologic and anatomic uniqueness routinely encountered. They have been drawn as if we were treating intact, unrestored, caries-free teeth. Many of these geometric forms, instruments, and procedural steps have not changed in more than 50 years.”

    Cliff

    Well, in terms of change, it’s true that much of what we’re doing today is similar to what we were doing in the past. I would say technology has exploded, though. But if you’re just talking about sticking instruments inside a canal, that’s much the same. If you’re talking about irrigating a little bit, that’s much the same, and some kind of a filling, that’s much the same. But in terms of their cookie-cutters and there’s no protocols, that’s completely just ludicrous.

    Those of you who have bothered to read the Schilder paper, the 1974 paper, the famous paper, the most downloaded, most recited paper in the world on shaping, realize there is not cookie-cutter. Each canal is harbored inside a unique root. The root is – has parameters and bulk and form and shape and so we – if you look at the Schilderian principles, there was never any measurements, there was never any cookie-cutter approaches.

    Every shape was unique. Every shape was specific for that root form, and that root that held that root canal system. And the root canal system was further discussed in terms of length, diameter and curvature or re-curvature. So, the shapes have been very, very specific for the anatomy.

    Lisette

    Okay. The next quote. “It is about restoring balance. It is about planning access, planning shape using a directed approach, and evaluating the response to treatment. Traditional endodontic treatment has been convenience-driven and endodontic-centric, primarily focused on operator needs, and has been decoupled from the restorative needs and tooth needs.”

    Cliff

    Okay, well I guess I have a different perspective, and my perspective is unique to me. We all have our own perspectives. So, I have traveled 5 million lecture-related miles. I’ve been in multiple continents. I’ve been in multiple, multiple dental schools around the world, and I would say that’s completely nonsense, because most endodontic departments are under the tutelage of restorative dentistry. Only the United States, not so much now, but historically, only the United States had a Department of Endodontics.

    In fact, in most schools today that don’t have post-grad programs, endo is under the Restorative Department. There is a complete linkage and coupling between endo and restorative. And I’ve been saying for my entire life, “Start with the end in mind.” So, the end in mind is the casting or the restoration in that tooth. And so, we’re always driven each step along the way to the restorative needs. So, I don’t really understand the decoupling part, and I don’t understand how it’s driven by just the endo part, because endo is only as good as the restoration that’s on top of that tooth.

    Lisette

    I mean probably the first question you ask yourself is can this tooth be restored before I perform endodontics on it, right?

    Cliff

    One of the most common questions posed in Endo 101, that would mean the very basement level, is the tooth periodontally involved hopelessly, or can it be made well? Is the tooth restorable? And sometimes we as endodontists, will even send the case by to restorative dentistry after a cleanout that might be sub-gingival or maybe to the crest, and we’ll entertain ideas with crown lengthening. Is it restorable? Are they comfortable doing this or would we best look at another alternative treatment plan?

    So, when we talk about needs, let’s be clear. If I’m teaching endo I’m not teaching how to make a line angle in a crown prep. If I’m teaching operative or crown and bridge, I’m not teaching patency. So, they’re fields and disciplines and they both have requirements for success, and they have to intermingle and coalesce. They can’t be over here working independently and over here working. It has to be done with the patient in mind.

    So, there are no dental needs from a dentist standpoint other than you’re serving the patient, you want to get maximum longevity. I’ve written many articles showing 25, 30, 40-year recalls, come on! So, let’s think about long-term results, and obviously, our endodontics is only as good as the restorative, and the restorative is only as good as the endodontics. So, focus needs to be very sharp and intentional in both categories to get the whole to be greater than the sum of its parts.

    Lisette

    Okay, well said. The next quote. “Scientific progress is generally hindered by trying to take the past into account as a way to move forward. The elimination of bacteria, an unreasonable and unachievable endpoint, has become the objective of endodontic treatment with clinicians and educators, going so far as to say that prevention or removal of microbes from the root canal system is the factor that determines if the treatment will be successful or not.”

    Cliff

    Well, I guess we should start off by saying that 100 percent of all endodontic failures, the ideology is microbes, so of course when we’re doing endodontics, our goal is to eliminate bacterial loads. We’ve never said, Ruddle has never said, “I clean every microbe out of every tubule, please step up and be like Ruddle.” No. In fact, we’ve even had Randy Cross on the show. We talked about bacterial loads and how you can reduce them. They never – with the Endocater, the Endocater, the device that measures – it measures through ATP. It’s a biomarker.

    They can tell you the residual load, and that we know from his work and work of others, that if you get the load down a certain percent ,you’re going to have a lot greater tendency to have long-term success. So, no, we’ve never cleaned out every bug. On the other hand, we never advocate leaving bugs intentionally because of this dormancy. Are we going to talk more about dormancy?

    Lisette

    Yes.

    Cliff

    Okay. So, I would say, to finish that one, your job is to reduce the vast majority of pulp tissue, bacteria when present, and their breakdown products. And if you’re looking at the sacred restoration at the other end, how good is that restoration at the other end if we have endodontic failure?

    So, I’ve practiced for 46 years. At least for the last 15 years of my practice, over 90 percent of all new patients that I saw had already had treatment, so there is a lot of endodontic failures. And sometimes there are restorative failures, okay, but let’s just say the tooth was failing, either endo or primary in restorative. All that has to be looked at. You can’t be really squeaky clean over here, battle, and fight to save every enamel rod, and over here you’re saying let’s leave a little bit.

    Lisette

    Yeah, I was also a little thrown by his claim that scientific progress is hindered by taking the past into account.

    Cliff

    Well, I – that’s one of my favorite quotes, but he just didn’t say the whole quote. And it’s not my quote, but it’s a quote I often use. If you want to create a compelling future, okay, a future with greater success and greater opportunity for patients, dentists alike, then you need to look at a future that is not about the past, but it takes the past into account.

    So, I think this remark was rather silly, because if you are going to the moon, you’re going to look at the body of science behind you and use that as a springboard. And yes, sometimes there’s incremental growth and sometimes there’s exponential growth, but it would be rather remarkably stupid to not take the past into account.

    Lisette

    Okay. The next quote. “Microbial dormancy may result from the formation of persister cells as well viable-but-non-culturable cells that resist traditional culturing techniques. It is likely then, that our success may come more from altering the microbial environment and inducing bacterial dormancy, as opposed to killing and removal. Perhaps a different, more conservative set of procedural objectives might be sufficient to induce dormancy.”

    Cliff

    Well, I could go on with this for 30 minutes, but we all know, let’s be honest, let’s be human, our goal is to clean out a root canal system. That means whatever is organically in there. Do we always do it? No. If you look at the Hess’s work that we presented many times on this show, we have really intricacies and complications and anatomical variability that is staggering. So, of course, technology has been coming, so we can clean better than we ever have. But do we get everything out? So, I’ll keep saying no, we don’t get everything out.

    But Ruddle has never taught let’s intentionally leave some bacteria behind. There was other inferences in that article where you might treat three out of four canals and put in calcium hydroxide and then have the patient come back in three months and take another CVCT to see if they were resolving their lesion. If they are resolving their lesion, you might leave the fourth canal dormancy.

    Let’s talk about dormancy. Dormancy is a subpopulation of bacteria, okay? So, you have a lot of flora, a lot of phenotypes, okay, but you got this cocktail of microorganisms. Dormancy is when a subpopulation of a certain phenotype goes dormant. And what happens is maybe there’s not enough substrate to feed them. So, what happens when there’s not enough to feed them, is they can either die, they can through planktonic movement, through communication, it could split off their population and swim downstream and set up residency in another area, a cul-de-sac, a fin, a tubule.

    But the subpopulation that is dormant, what wasn’t mentioned in the article is it can be turned on and turned off because there are clonal switches and the clonal switches can speak. In other words, toxins can turn them on. Antitoxins can turn them on. Oxygen can turn them on. So, maybe you’re doing a crown prep and you’re taking impressions and there’s hydraulics, maybe get a few oxygen cells in there. This can turn on these dormant bacteria and they can repopulate and come back, go into log phase and they can be as bad as the original infection.

    So, yeah, that happens. I’m not arguing there’s not dormancy. When we leave them behind, maybe we – they calcify because maybe we cut off their substrates by sealing the root canal system in our third graphic, and if we did that perfectly along with the coronal seal, you could say there’s no substrates and maybe they stay dormant.

    But you know what, we’re not trying to teach around the world an anecdotal sometimes event; we’re trying to teach predicable treatment. I like his concepts a lot on restoration and how the restorative should drive the endo. I’ve never had a problem with that, cause I taught that before John – I ever knew John or John was even in dentistry, okay? So, that’s been a very long-time discussion. But really, we need both, and we need both areas to step up and be all that they can be.

    Lisette

    Okay. Next quote. “The convergence of three pieces of technology has allowed a complete shift in the practice of endodontics: the microscope; low-dose focused field CBCT; and root-form appropriate, heat-treated NiTi instruments. This new triad is now focused not on removal of bacteria, but on preservation of the pericervical dentin.”

    Cliff

    So, you’re saying there’s a technological triad? I thought we were talking about a microbiological based triad. The microbiological based triad was really about serving patients. It was about removing diseased tissue, making sick people well. It was about putting exquisite restorations on these teeth, showing the cusp. Those teeth that tend to fracture, we wanted to cover them. If they aren’t heavily restored, maybe bonding can do it. But back to your question about the – just say the last part again.

    Lisette

    The new triad is now focused not on removal of bacteria, but on the preservation of the pericervical dentin.

    Cliff

    So, in other words, if I buy a microscope and I buy a CBCT and I’m using heat treated NiTi files, I’m home free. I mean that’s what I need to have to be successful. What about all the evidence and science behind – well let’s talk about the biology. Let’s not talk about tools. Tools come and go like dirty laundry. So, yeah, I agree. I had a microscope, you know, back in the mid-80’s. Okay, we used NiTi, started in ’91, ’92. Yeah, heat treatment came along recently, like in the last 10 years.

    So, we have CBCT now, something else to help us plan our treatment. Why don’t we use all that technology and agree, you know, but back to the minimal instrumentation, not only do we want to save tooth structure in our access cavity, and if you have a big caries wall, of course, just go through the lesion itself and you might be able to get into the pulp chamber and do everything properly.

    I was talking about facial accesses on mandibular incisors 25 years ago, John. So, hello, it’s like because 35 percent less tooth structure was destroyed doing facial accesses on mandibular incisors. So, the access is always jockeyed and can be assigned based on the tooth, the presenting disease model and then where we’re trying to go with the patient. But at the end of the day, the triad isn’t a bunch of tools. It should be based on biology, and I would think, microbiology.

    Lisette

    Okay. The last quote I’m going to go to is how he – how Dr. Khademi ends his article with a quote from a friend of his, Dr. Glen Doyon, who is a restorative dentist turned endodontist. And so this is Glen Doyon’s quote in the Khademi article. He says, “One of the problems of the legacy endodontic culture is that they don’t really know what works and what does not work long term. I’m talking about more than four years for the patients. The general dentists see and have the follow-ups because the patients come back to their office.”

    “People come back to the general dentist all the time to have their teeth cleaned, so the general dentists see what goes wrong. Endodontists don’t really know what works and what doesn’t over a long period of time. Endodontists think lack of evidence of failure is success. If you ask them, they think their cases are 95 percent successful. They just don’t know.”

    Cliff

    Did you say he’s downing endodontists? I guess he just called himself stupid.

    Lisette

    I guess he doesn’t have very long recalls.

    Cliff

    Well look, and I don’t have any problem with any of these guys, you know. I hate it in the profession when we try to, you know, elevate a villain to elevate a hero. So, it doesn’t have to be fame or glory or power or money. There is really a biology, and what we don’t understand we’re discovering, and I’ve always had vigorous recall systems. Hey Glen – is that his first name?

    Lisette

    Yes.

    Cliff

    Double “N”?

    Lisette

    No.

    Cliff

    Glen. Glen, if you charge enough for your endodontic procedures, your patients will find you. They’ll come back. They’ll want to see how they’re doing. There was a lot of jokes about this about 20 years ago, how to increase your recalls. Increase your fees, because when people pay for something, the more they pay the more they value it, and the more they value it, the more they want to make sure it’s being taken care of and everything is fine.

    I have vigorous recall systems, as good as any general dentist. People come back frequently, all the time, and we don’t see them, Glen, for four years. We see them at six months, one year, two years, five years, 10, 15, 20, 30, 40, and I’m doing 40-year recalls. So, I know many endodontists that are like myself and I know that some probably don’t worry so much about recalls. That’s really just specific to the operator. So, if you want to see what you’re doing, you can have a recall system. And I do think that endodontists perfectly know what’s going on with their work, because when they do a root canal on the posterior abutment, Glen, of a four-unit bridge and it blows up post endodontics, do you think they don’t know it’s failing? Do you think the general dentist says it’s my fault, it’s the bridge?

    No, they get sent right back to the source and the foundational work, the endodontics. So, that’s kind of an ignorant comment, and I don’t know why that would even be made, because I even have general dentists that mail me recall films on my patients.

    Lisette

    Well, he evidently thought it was a powerful enough quote to write an article with it. So, clearly, Dr. Khademi makes some assumptions that are problematic and actually, frankly, sometimes just mindboggling. I’m not really clear why he thinks an endodontist can’t consider the restorative needs and why that’s a new concept. Why can’t he consider the restorative needs and at the same time have an adequate removal of bacteria? So, that’s just – seems problematic to me.

    Cliff

    One thing that’s missing in a lot of these discussions, and I don’t know, maybe these guys don’t do this in Durango, Colorado, where Khademi is from. Maybe Glen Doyon doesn’t do this. But it’s called study clubs. It’s how our profession grew. If you go back to the ‘50s and the ‘60s and the ‘70s, we weren’t even recognized by the ADA as a special area of dentistry until 1963, so how did all that get learned back then?

    Because it was called “interdisciplinary treatment,” and study clubs forms in all the major cities and little towns, and 20, 30 doctors would go in and share their cases, and if you over shaped your canal, don’t think the general dentist didn’t see and said, “You weakened the root. Look, it fractured.” Okay. So, I’m for both sides. Let’s keep all the tooth structure we can, and let’s do the best endodontics we can.

    Lisette

    Okay, well let’s just move on.

    Cliff

    We can co-exist, right?

    Lisette

    Right. Let’s move briefly to an article that Dr. John West published –

    Cliff

    Oh yeah.

    Lisette

    – in April of this year called, The Endodontic Triad: Dead or Alive?. And in this article, he identified 10 respected clinicians who generally get good results and but who also do things very differently than he does. And he asked them to reveal what they do to shape, what they do to clean, and what they do to pack, and he also wanted to know what sealer they’re using. So, guess what the results were?

    Cliff

    They were all over the place and they were as diversified as the colleagues who submitted their work. So, we had everybody doing something slightly different, but everybody was doing what? Everybody was using instruments, and they reported the files they were using to clean their canals. I just might say this. Many of these so-called canals that are instrumented, they’re neither cleaned nor shaped, so you’re relying on technology. And lots of evidence has been – look, I wrote the preface for laser in endodontics, laser activated irrigation.

    And in that preface, I speak a lot about where we’re going into the future. But they need to understand that flow channels help fluid dynamics. You can’t say non-instrumented canals anymore, because too much work in that laser book that I wrote, there’s a whole chapter on canal preparation. And that’s for lasers, and GentleWave wouldn’t be that dissimilar.

    So, anyway, they all were doing some kind of instrumentation, but the triads did, and they say now it’s binary. Some of them were using different methods to irrigate and clean, GentleWave, lasers, EndoActivator, hand-held syringes. They were all doing something, so that seems to be intact. We just don’t agree on it. They all instrument. We just don’t agree on the size and the parameters. And they’re all filling.

    And of course, when you make these truss accesses and orifice directed accesses and ninja accesses, you’re bringing up a whole new level of complication for general dentists. I’m an educator, so I’ve taught tens of thousands of dentists around the world to try to do the best they can do. And everybody wins when they have an access where they can visualize the orifices. They can look for fracture, cracks in the axial walls and stuff. So, they all have in common that they were cleaning and shaping and filling, but yet they say it’s a uni-ad or it’s a bi-ad, but it’s not a triad. So, maybe – I’ll be kind.

    Lisette

    I want to point something out. One of the clinicians surveyed was Dr. John Khademi, and he apparently now uses GentleWave. So, after downplaying the need to remove bacteria, now he’s using GentleWave, so I guess maybe he’s given up on trying to induce bacterial dormancy.

    Cliff

    Well, we talked about that in an article you and I wrote. I mean I don’t think the world really knew this, so I’ll just be kind of blunt here. Two guys were going at it in Dentistry Today, but most of the world didn’t even know it except the two guys who wrote the articles. But I got pretty offended when Schilder was thrown under the bus because he never understood what Schilder taught. If he did, he wouldn’t even be saying such ridiculous remarks.

    Schilder never gave a cookie-cutter approach. Every one was what, funnel shape, it was a taper in the apical third or maintain the original anatomy, maintain the position of frame, keep foramens as small as practical. So, those were things that we’re all still doing every single day.

    Lisette

    Okay, well I think you mentioned this. John West did point out that some of the clinicians were opposed to using the word “triad” when they were doing the survey, and they preferred “uni-ad” or “bi-ad.” Well, you know, bottom line is they were all doing something to clean, something to shape, and something to path. So, perhaps this is just a problem of semantics.

    Cliff

    Well we gave an article, didn’t we? Or we did a show, a segment. I think it was called Splitting Hairs. And we talked about the difference in some of these concepts are something like a human hair. And a human hair is small is 06, 06 file. A medium one is an 08, 08 file. Think 08 file. And then a coarse human hair was a size 10. A lot of the shaping below the orifice, we’re splitting hairs. In terms of the access cavity, geez, you got a big blowout lesion, use it, go through it and play off it, okay?

    I don’t think these are controversies, but I think sometimes, I’ve noticed after almost 50 years, that sometimes people have to come up with a new disease model or a new way to look at it so that they feel good about themselves, they have something to talk about and that they can forward this clandestine ideas because they don’t have big public means [sounds like]. They have little – they’re almost like zealots, these people, and I notice there’s a fanaticism about tooth structure. Hey listen, save every gram of tooth structure you can, but how about the endodontics?

    Lisette

    Well, it’s good this all promotes some discussion, so it’s good to talk about it.

    Cliff

    And it didn’t get solved today.

    Lisette

    All right. Well thank you. Good information.

    CLOSE: What Does Phyllis Think?

    Lisette

    Okay, so we’ve had challenges and then we’ve had controversy, and now we’re going to finish with some fun. Another segment of What Phyllis Thinks. So, if you think of Disney movie, something along the lines of Snow White, usually the female protagonist is in the woods singing and all the woodland animals and birds are gathering around her. Well, that’s my mom. So, she’s definitely an animal person, so this segment of What Phyllis Thinks is going to revolve around what she thinks about animals and the human/animal connection. So, are you ready for some questions?

    Phyllis

    I’m ready.

    Cliff

    Grrrr. Oh, sorry.

    Lisette

    Okay. So, you grew up in Michigan, moving around a lot. Besides the standard cat and dog, what other kinds of pets did you have?

    Phyllis

    First we lived on a farm when I was really young. And that was the standard cows, ducks, chickens, all those fun things. But then my dad decided to go to college and packed up family of five, and we lived in a little, small house trailer and we had over 21 different pets during the next ten years. And I just assumed everybody lived the same way that we did, and they were not the typical dogs and cats. We had raccoons, a flying squirrel, a possum, a mother possum with all the babies hanging on her tail. That was only in the house one night. My mom put her foot down. A red fox, skunks, rabbits, goats and some snakes.

    Cliff

    Excuse me?

    Phyllis

    Yeah, I know you don’t like the snakes.

    Lisette

    So, were these pets in the house with you? Were they in cages?

    Phyllis

    They would start out in the house. I remember the raccoons started out in the house until they figured out how to open the little slider door and get out of the house trailer and ran away, and we had to find them, and they were in a Mulberry tree and had eaten all the mulberries off the tree. And then my dad built this tremendous, you know, two-story cage.

    He was always building cages and things, and they had a little ladder they would climb up and that’s where they slept on that little platform. It was a little like cave they slept in, and they would – we would feed them a boiled egg, and they would tuck it under their arm and carry it up the stairs and then roll it off the top so it would crack the shell so they could eat it. They were very smart. So, yes, they would start in our house and then get moved to a cage as soon as he got it built.

    Lisette

    Well, what about the flying squirrel, and did it really fly?

    Phyllis

    Yes, the kind that has the webbing that flies.

    Lisette

    Uh-huh. So, it glides more?

    Phyllis

    Yeah.

    Lisette

    Okay.

    Phyllis

    I have a funny story about that I have to share.

    Lisette

    Okay.

    Phyllis

    My dad – we were very poor, so he had one nice shirt and one nice suit for church. So, we went – it was living in the trailer with us, and we went to church and we came back and somebody said, “Oh, your squirrel got out.” Of course, everybody knew where all the animals came from. “Your squirrel got out and he’s in that tree over there.”

    There was this big mansion house right near the edge of the trailer park, and my dad immediately took off his coat, raced, he was climbing up the tree to go get Willie the squirrel. And he gets almost to him, and the squirrel flies across to the chimney of this great big house. It was three or four stories tall. It was a huge house. Disappeared at the chimney. And we’re going, “Oh no!”

    So, my dad races down the tree, knocks on the door, says, “Can I check your furnace?” This was in the summer fortunately. So, he goes racing in, opens the door of the furnace and he’s looking in, looking in, “Willie, Willie” and splat, Willie jumped and landed right on his white shirt, and we rescued Willie. And we actually let him go soon after that.

    Cliff

    Did you rescue the shirt?

    Phyllis

    I think – I don’t know what happened to the shirt.

    Cliff

    Sounds like it got whacked.

    Phyllis

    I was too young. So, that was my dad in these stories. He was just a crazy nature person.

    Lisette

    So, would you say he was the one that influenced all these pets?

    Phyllis

    He did. I think starting out on a farm, you’re around a lot of animals. I loved that. And then he brought them all home. He had a box in the truck, and every time he’d see something that he wanted to catch and bring home – he got skunks, he got raccoons, anything he would see, he would slam on the brakes and we’d all sit there and wait. My – I could imagine my mom now, what she must have been thinking, and he’d run off into the woods or the field and get these animals and we’d take them home.

    Cliff

    Basically, he devastated families by kidnapping offspring.

    Lisette

    Well, that does show some skill though, that I didn’t know he had, because it’s not easy to catch these kinds of animals.

    Phyllis

    No. And why would you do that? I think it’s outlawed now to do stuff like that.

    Lisette

    Okay. Well, when I was a kid we had a Norwegian Elkhound, Kizzy, and then eventually she had a baby, she had puppies, and we kept the one, Lady. And these were followed by Katy, Oscar, Lucy and Jake, all Norwegian Elkhounds and Dobermans.

    Phyllis

    Yes.

    Lisette

    So, what did you like best about these breeds and what were the challenges?

    Phyllis

    Well, the Norwegian Elkhound was Mary, our receptionist at the time, she had a breeding kennel, and she gave us the first puppy, Kizzy. And so that – we had never heard of them before. They’re the oldest – they’re 6,000 years old, the Norwegian Elkhound breed. They’re the original domestic dog. And so, that’s how we got her. And loved that and then she had the puppies. We kept one, and then Lady got killed on the road.

    And then we ended up getting a Doberman puppy to replace Lady and I never planned on having Dobermans, but his parents had a litter of, I don’t know, 12 or 13. They have big litters. And so they gave us Katy, a little tiny thing at the time. And that’s how we got a Doberman. So, I had to learn all about them, how to raise them.

    Lisette

    And we also got her tail clipped and her ears done. At that time, that’s what you did with Dobermans.

    Phyllis

    Yeah, they don’t do that anymore.

    Cliff

    They were much more expressive though when you get the ears done. There’s all kinds of body communication going on with those ears.

    Phyllis

    They flip them around like antennas.

    Lisette

    Yeah, I do remember her. And like she’ll – it will change like if she hears something.

    Phyllis

    Yeah.

    Lisette

    Okay, so our first Doberman was very strong and a bit out of control, so she went to dog school. Can you describe this experience and would you recommend dog school for someone with an out-of-control pet?

    Phyllis

    Yes, definitely, especially large, strong animals. It’s the best thing you can do for yourself and your family, and for the dog, number one. And I was the one that had trouble getting her to do the things she was supposed to do, and it’s a long, sad story, and eventually she stayed an extra week, and I –

    Cliff

    No, eventually the girls and I took the dog home. We left you at the kennel, and you had another week of training.

    Phyllis

    And I passed.

    Lisette

    See we all – all four of us had to show that we could –

    Phyllis

    Everybody in the family.

    Cliff

    Interact with the dog.

    Lisette

    Yeah, and you were the only one who couldn’t, for some reason.

    Phyllis

    He kept saying, “She doesn’t believe you. She doesn’t believe you. She knows you still love her. You’ve got to make her think, you know, there’s a line in the sand.” And that was just so hard for me to do.

    Lisette

    You know what? I would say that of us four, you are the most soft-spoken, so that probably had something to do with it.

    Cliff

    And what did you say? Oh.

    Lisette

    So, a lot of people think pets can help with mental health, so I imagine pets have been pretty busy during the pandemic. Do you recommend pets for someone having mental health issues, and why or why not?

    Phyllis

    I recommend it if they like animals, but it is like bringing home a new baby. I mean it’s a lot of work. So, they have to – for it to work, they have to like doing that, and I think it’s so great if they do, because it takes them out of their head, out of themselves, and if you’re caring for something else, you’re a better person.

    Lisette

    Probably if you can get past like the first month, it will help your mental health. It might get worse initially.

    Cliff

    Not that different than raising two girls, right?

    Phyllis

    The year after we were married, he brought a puppy home from college. Somebody was giving our puppies. Do you remember that?

    Cliff

    No.

    Phyllis

    It was the cutest little, tiny brown puppy. He brought it home and it was like I was so excited. I mean this was like my dad bringing animals home. But it lasted one night and he had to take it right back and give it back to the people that were passing them out. It was just way too much work for me working full-time and him going to school full-time. It didn’t work out. And he doesn’t even remember it.

    Lisette

    All right, so recently, Cassie, your miniature Cocker Spaniel, has had some health issues. What has been challenging about this and how far do you go financially and ethically giving medical care to a pet?

    Phyllis

    Well, the financial part depends on your own, you know, what you can do, and emotionally you have to know when it’s time to let go, and as an animal gets older it’s on your mind more, and she’s 12 and a half now, so when this happened, we were thinking this might be it. It turned out it wasn’t. And she’s fine now. But you do have to know when the time comes to let them go.

    Cliff

    You got to know when like to put Phyllis down, when to put the dog down, you have to know these things.

    Phyllis

    Yeah, so that’s – it’s just everybody is different, what they’re willing to do.

    Lisette

    Okay. What about – what is the most annoying thing that you witnessed other pet owners do? Maybe you can also answer this one, Dad, too. Anything annoying?

    Phyllis

    In behavior? Annoying things. I don’t like dogs that jump up on you or that are menacing.

    Lisette

    What, you don’t like the dog or you don’t like the owner letting the dog jump up?

    Phyllis

    The owner letting the dog –

    Cliff

    I always blame the owner. I just got bit on the arm recently, as you know, and it was a lady I have seen multiple times over months and months and months, and her dog just took the liberty to get a little chow on my arm. It must have thought it was a rubber bone. It went right through the clothes and everything. I was mad at her, but not her dog.

    Phyllis

    Yeah.

    Lisette

    I have been in situations where –

    Cliff

    I had her put down.

    Lisette

    – the dog is on a leash lunging at me, barking, and the owner is going, “Don’t worry, they don’t bite, they don’t bite, they don’t bite.” And so, I’m like I don’t know.

    Phyllis

    I know.

    Cliff

    It feels like we’re on bone already.

    Lisette

    Okay, so now just to close out, what is the hardest challenge about having a pet?

    Phyllis

    Oh, probably knowing that they’re going to leave before you do. That’s just the hardest thing to go to that place and you just – you want it to last forever and you know it’s not going to, so you enjoy every day and love them all the more.

    Lisette

    Okay. And what is the best part or the most rewarding part of having a pet?

    Phyllis

    The unconditional love. They are always excited to see you and you can’t do anything wrong. I love that part of it.

    Lisette

    Okay, well thank you for that information, and thanks, Dad, for your input, too.

    Cliff

    Yeah, I’ve become very tolerant.

    Phyllis

    He has. Kathy is the first indoor animal that we’ve had the last 12 years, and he’s been a good sport and he loves her as much as I do.

    Cliff

    Now she can read the paper with me.

    Phyllis

    Yes, she does.

    Lisette

    Okay. Well, that’s our show for today. See you next time on The Ruddle Show.

    [music playing]

    END

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    03.03.2022 Update

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