There has been massive growth in endodontic treatment in recent years. This upward surge of clinical activity can be attributable to better trained dentists and specialists alike. Necessary for this unfolding story is the general public’s growing selection for root canal treatment as an alternative to the extraction...
Patient Protocol & Post Removal CBCT & the Post Removal System
This show opens with Ruddle and Lisette highlighting the annual AAE meeting that kicks off this week in Phoenix, AZ. Next, we will debut a new segment called, “Every Patient?” Should every patient receive a CBCT scan? Let the discussions begin. Then, Ruddle is back at the Board delving deeper into post removal utilizing the Post Removal System. The show closes with another new segment, “Influencers;” Ruddle and Lisette will each reveal a childhood friend who greatly influenced their lives.
Show Content & Timecodes00:59 - INTRO: AAE Annual Meeting 07:35 - SEGMENT 1: Every Patient? – CBCT 28:13 - SEGMENT 2: Post Removal with the PRS 54:30 - CLOSE: Influencers – Childhood Friends
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There has been massive growth in endodontic treatment in recent years. This increase in clinical activity can be attributable to better-trained dentists and specialists alike. Necessary for this unfolding story is the general public's growing selection for root canal treatment...
Ruddle on Shape•Clean•Pack Supply List and Supplier Contact Information Listing
Ruddle on Retreatment Supply List and Supplier Contact Information Listing
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.
…Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle.
How are you doing? Glad to be here. Good to see you. Start over again. What was I supposed to say?
Okay. Those types of stuff you just said.
INTRO: AAE Annual Meeting
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle.
Welcome back. Good to see you again.
Okay, we wanted to just start off our show today talking about the upcoming annual AAE meeting, because when this show launches that will be the same week the AAE meeting kicks off in Phoenix, Arizona. And I think that it’s going to be in-person this year, correct?
Yes, after two years, everybody is very excited about the physical meeting, and for those who can’t come, there’s still a virtual component.
Okay. Well I was comparing the educational tracks from this year with those from last year and I noticed a couple things I found interesting. One, the Cognitive Dissonance track has been replaced with Clinical Ethical Dilemmas which is intriguing. And then the Tech 2021 track has been replaced with Practice Management and Teamwork, a favorite topic for us on The Ruddle Show. So, we have a list, and why don’t we bring it up. Maybe you can just briefly run through the Educational Tracks.
Well the first one is Clinical/Ethical Dilemmas, and that’s a very important topic to me, because having spent most of my career in nonsurgical retreatment and surgical retreatment, you see a lot of people’s failures, and, of course, you have to talk to patients, referrals, and manage all those conversations, so I think that’s an important track. I think it’s Al Gluskin and there’s a few others. They’re going to talk a little bit about how to respond to substandard endodontics, so that could be good for people to want to see.
And then, of course, Richard Schwartz, he’s a really great endodontist, but sometimes he talks about buildups and post phases and placing a post and caries control and the subgingival, and also, he talks a lot about actually getting a tooth prepared to do good endodontics. So, that’d be a good one to see. We had something like that on the show featuring the same guy and we called it on the segment, “Whose Job is it?”
Right. We talked about his article that he wrote about the endodontist, you know, starting the restorative work, and that caused a lot of controversy with the AGD president and the AAE president, and so we just discussed like whose job is it. So, of course, that – now he’s talking about it in that category, so that’s interesting. All right, next up we have Interdisciplinary.
Well in interdisciplinary treatment, there’s a couple good ones. You know, you might think endoperio, you might think perio-cross, you might think endoperio-cross. You might think pedo, you might think eruption, ortho-endo, but I like the one on sinus. It’s Rod Tataryn and an MD named Dr. Craig, and they’re going to talk about odontogenic interrelationships with sinusitis.
Then non-surgical root canal therapy and that’s a pretty broad track. What does that include?
Oh my goodness, you’re going to see people like Azevedo, and that’s Bruno Azevedo, and Mohamed Fayad. They’re going to talk about CBCT, so right off the bat, I’ll just go, kind of tick through it. Diagnostics, okay, so all about diagnostics, then Hebert’s going to talk a little bit about isolation and how to get teeth pretreatment ready for endodontics. Then there’s the access cavities. There will be discussions about that.
We’re going to have people talking about scouting canals. Can you imagine that day meeting? They need it, they need it. And then there’s going to be shaping. There’s going to be fluid and disinfection discussions. There’ll be obturation, restoration in endodontically treated teeth, resorptions and broken instruments. So, what I thought about all these tracks is there’s a lot of overlap, but you wouldn’t really know what’s interdisciplinary except all the things I said, but then go ahead, take us to the next one.
Well, I did notice that in this nonsurgical root canal therapy track that Dr. Shanon Patel, who was on our show, he’s going to be talking – on our show he talked about CBCT, but he’s going to be talking about root resorption.
Right. On our show he was talking about CBCT related to trauma and then fractured teeth, and now he’s going to talk about resorptions and CBCT and diagnose those, so that will be interesting. Mike Ribera, how to integrate new technologies into the workflow. And I don’t know, do we have something else here? I mentioned Brent Hebert already.
Yeah, he was going to talk about building the teeth up and getting them set for endodontics.
Okay. All right. Well then there’s the pain track next, and I imagine that’s always a hot topic because, you know, pain management, you don’t want your patients to be in pain. But I thought it was interesting that Dr. Ken Hargreaves, the editor of the JOE, last year he gave a presentation in this track and it was called a “Potpourri of Pain,” and this year his presentation is called a “Cornucopia of Pain Relief.” So, I just like his title.
Yeah, so go catch Kenny, he’s really brilliant. He’s still the editor of the JOE, one of the smartest guys I’ve met in endodontics. So he’ll have a really good slant that will be helpful. John Nusstein going to share his ten-year local anesthetic research, and that’s very profound and we see a lot of hot teeth, don’t we?
Okay, then we have Practice Management/Teamwork, and I saw that there was one presentation called “The Rockstar Assistant.” That also covers like the business of endodontics. There’s information about DSO’s, joining a DSO. There’s stuff about communication and life balance, so there’s that. And surgical root canal therapy?
That’s a really interesting tract, because it’s the last stop, isn’t it, before the implant. Arnaldo Castellucci is going to have a nice talk there. He’s got textbooks also to back this up. You might want to just check him out. Another great one would be Stephen Niemczyk. Now Stephen is a very talented surgeon and I’ve known him for many decades. And he’s going to talk about how you can use piezoelectric, the piezotome, to make bony windows and take out cortical plates and then put them back in intact. He’s going to talk about incisions.
And then I guess the other one would be Damiano Pasqualini. He’s going to talk about CBCT and surgery and all that. So, there’s going to be a lot of information.
And then to finish off our list, there is I think 34 submitted presentations, and they have a wide range of topics, and they range also from 45 minutes to 90 minutes, so it looks like it’s going to be a big production, an exciting event.
Pack your bags; it’s time to get in the air and go to Phoenix.
SEGMENT 1: Every Patient? – CBCT
So, we have a new segment to debut for you today, and it’s called “Every Patient?” And that’s with a question mark, “Every Patient?” And the point of this segment is to examine patient protocol and ask ourselves if every patient should receive exactly the same treatment or if treatment should be individually tailored to the patient’s specific needs. Or perhaps maybe there are even other factors, external to the patient, that are influencing patient care.
So, to kick off this segment, we’re going to focus on two higher end technologies and if they should be used on every patient, and we’re going to start – and those two technologies are going to be CBCT and GentleWave. And we’re going to start with CBCT and probably we’ll only have time today to do the CBCT, but join us later in the season for part two where we’ll talk about GentleWave.
So, let’s start with CBCT. Should every patient receive a CBCT scan?
I guess we should introduce the buzz words to our general dentist friends. They probably know it, but it’s called ALARA, as low as reasonably achievable. So, we should always keep that in mind, and later I’ll talk a little bit more about the radiation side. But the excitement about CBCT is and if you can get by the $100,000 piece of equipment, only got in the United States, for your curiosity, since 2021 is last year, but it came in 2001, so about 20 years ago, so it’s pretty new, but a lot of people have the units. So, there’s a lot of excitement because you can see in three dimensions, obviously.
So, the excitement is you get new technology, you want to use it, cause you spent a lot of money for it, so everybody is going to get it, right? Well not necessarily. You can do a lot with your films and taking different horizontal angles, but of course, that’s not still 3D. So, what is exciting is you can see things like resorption. You can see a lot of times fractures. In traumatic injuries when we had Patel on the show, he showed us things that you couldn’t even see without 3D, so it’s really good for that.
So, sometimes then you can see root fractures, calcified canals. Instead of trying to chase them and mutilate the teeth, sometimes we can get that axial slice and move over a little bit, and there it is. Tooth anomalies, taurodontia, we can have radix entomolaris, we can have radix paramolaris, we can have dens in dente, we can have three-rooted bicuspids, so all these things can be seen in really great detail with a 3D scan.
So, probably then you can argue that if you can treatment plan and get your workflow going cause you are already clearing your mind what it is to do, how many canals there are, curvatures, links, directions, stuff like that, middle foramen, neurovascular bundles, sinus. If you know about all those things, I think you’re going to start your case with probably a lot more confidence.
People do charge for them. I don’t have any problem with that. I don’t know if I can tell you an average, but I saw it bandied around in my little lit review to get ready for this segment, $200 to $400 is not unusual, but we must add that many dentists charge a nominal fee significantly less than that, and some don’t charge at all.
Okay, and it’s kind of my understanding that this might be an extra cost that comes to the patient separate from their treatment fee, like they might say well you should have a CBCT scan, and that will be an extra $200 to $400.
That sounds pretty much language to the patients.
But it makes sense that you would want to make up the cost, and it does seem that if you can see so much more and you can improve your diagnostics and know where the danger zones are, like you were saying the sinus tracks and neurovascular bundle, if you can see so much better, then it sounds, of course, you would use it on every patient. Well what do the people who think that you should not use it on every patient – what is their argument?
Well, their main thing probably is radiation and cost. And when you hear this bandied around, which it’s frequently bandied around in various forms, but a lot of them is the AAE discussion forum. The reason I mention that forum a lot is that’s kind of what the endodontist in North America predominantly are talking about, it’s what’s resonating in the community, the conversation in the marketplace, so we refer to that a lot because that’s where you hear a lot of talk.
They just recently had a huge discussion about fees. I would say when you’re learning a new technology like when I was learning the microscope, I didn’t charge patients for my time. I mean yes, I did, but at some point, what used to take me an hour now is taking me an hour and a half, I didn’t raise my fees to take into my learning curve. So, I think you learn and give back, that’s fine, and then as you get confident and you become proficient at interpreting, you know, you got to take the films, you got to store then, you’ve got to retrieve this information. You got to learn how to use your mouse and look at different coronal, frontal, sagittal, axial slices, so you got to look at these three different views.
And you got to know how to do that and it takes time, but once you learn how to do it, there’s nothing wrong with getting a return on your investment.
Okay, like are – does every tooth in the mouth – are some teeth more straightforward and maybe you don’t need a CBCT scan or maybe like –
That’s the big debate, you know. You can’t teach experience, but when you have experience and I’ve said this many times on the show, when you teach and you give workshops, not everybody wants a 3D printed model. I don’t. I want a natural tooth still, because that’s what we work on our practices. Over the decades I saw – well I’m going to just say tens of thousands of extracted teeth in my hand, and you could hold them and look at them and see what you couldn’t see when they’re in the mouth, but it was kind of like my CBCT in my hand, I could flip it around.
So, you learn a lot from experience, and sometimes – I thought it was your line, but I think younger dentists like it because it makes the – what’s the word here we said, it makes the –
– obscure obvious. And so, if you’re trying to – if you’re younger and you don’t have all the experience, you haven’t seen like 100 mid-mesials in the last 10 years, then obviously if you can see with a CBCT you’re not going to tell that colleague not to do it. I think CBCT is fabulous, and I don’t even think it’s a discussion. I think we just need to take the patient into account, and if it’s a – back to your point, if it’s a maxillary tooth, there’s no history of trauma, I think periapical films are fine. I mean I practiced for decades with no CBCT.
I had a success rate more than 99 percent. I’m very proud of that, and if our regular treatment didn’t work, our conventional treatment, we might have to go to nonsurgical retreatment and sometimes even then you can look at different studies, you can push that success rate even higher if you go to microsurgery. So, now, you know, it would be like telling somebody you don’t need a microscope. Well, I didn’t have a microscope my whole first 20 years either.
So, you can learn a lot from experience, but you can’t teach it, you have to get it and obtain it. And then, of course, it keeps us out of trouble. We can treatment plan for no surprises. Our workflow is going to be better, and I think we’ll get better results. So, I would say that’s sort of the big things, the cost and the radiation. I wanted to –
How different is the radiation level, like from an X-ray to –
I wrote this down.
– a CBCT scan?
It’s stunning to me.
Is it very different?
Well they keep arguing on the forums and different places it’s just a little bit more. I looked at this for about three hours yesterday, so if you look at Patel, he wrote a very nice article, and in the article he said that with a small field of view with new equipment, cause the CBCTs have changed a lot in the last 20 years. Sieverts is the – is how we measure the doses and he said that a periapical film is 1.5 micro sieverts. 1.5 is what you should remember.
He said if you take a small field of view, 4 centimeters by 4 centimeters, that’s 13 micro sieverts to 44. That’s a big range, isn’t it, 13 to 44, just remember the units, micro sieverts. Well that alone is 9 to 30 times more than a periapical film, that’s pretty astonishing to me. Now here’s the worst news. That’s the lowest I could find in the literature. But if you just look at the literature, Google it, find out, endodontics, don’t go to medicine, go to endodontics CBCT, they’re quoting 19 micro sieverts to 1,073, remember a periapical film is 1.5.
So, radiation is a concern, and I think if we stand in the patients’ shoes, everybody is always saying well it’s just three days in the sun or it’s just a flight to New York and back, Cliff. Remember, they’re doing all that anyway. They’re going to the beach, they’re out in the sun, they got their cell phone by their ear most of the day, they’re watching television, they’re running their microwaves, they’re flying at high altitudes for hours and hours and hours.
So, I would say isn’t it great we have it; be responsible, certainly – and okay, surgery, take a scan, a mysterious failure. What if you take a periapical film and the failure is obvious. Missed canal, cause you take off and you go and you look at rules of symmetry. We’ve already talked about the 14 ways to find a missed, previously missed, aberrant or calcified canal.
If you take a film and you obviously notice lack of symmetry, I don’t know if you need one. What if it looks like it was well treated, no matter which horizontal angle, distal, mesial, straight on, and it always looks pretty good, you might want to take a scan because you’re going to probably find out again what the obvious is.
Okay, so maybe on like a straightforward like front tooth you might not need to do it if you –
Some molars, some bi’s. I use this because I think we can all relate, single rooted teeth usually maxillary anteriors, but to your point, I think a lot of cases are pretty straightforward and your three angles are going to be absolutely fine. If you’re not experienced or, you know, you just haven’t seen enough cases yet, take the scan, but remember we didn’t always have it.
Sometimes when you look at today’s discussions on forums, it’s like they couldn’t even do endo without a microscope. They would not even be able to take the next step forward without a CBCT. I understand where they’re coming from. I totally understand. Remember, I’ve been involved in a lot of R&D and technology and new things coming to market. And they’re good. If it’s easier, better and faster and it serves your patient, I think just weigh the risk versus the benefits and always keep that in mind.
Now I heard you kind of imply that maybe in the retreatment situation if you know, like you think it’s a missed canal, do you think in the retreatment situation it would be a good idea probably to do a CBCT or are you saying that still, you know, depending on your experience, depending on your knowledge of why teeth fail that maybe it’s not necessary?
Well that’s a good point. You’re pressing me a little harder. First of all, I don’t want to sound like I’m 400 years old. If there’s new technology and everybody can benefit, I’m just saying be aware of the radiation. It doesn’t seem like it’s just insignificant, but back to your point. What is a patient presents, they have swelling, I’m making this all up, psycho-drama role-playing, and they have large lesions of endodontic origin apically around the roots. The general dentist put them on antibiotic. By the time they come and see me they’re asymptomatic, they can actually chew on this failing endodontically treated tooth.
If I see this failed short, I pretty much know what to do, and I don’t know that a CBCT is going to help me. Now you might argue, well where’s the neurovascular bundle? What if the roots are sitting right on top of that bundle clip or what if they really look like they’re sitting on it, but in this view we can see they’re either lateral, lateral to it. So, yes, if you’re worried about having an extrusion of your irrigant or a surplus after filling the event where maybe obturation materials could get into the bundle, of course that’s helpful.
I never had one of those in almost 45 years of practice, never had a paresthesia, didn’t have a hypoesthesia, didn’t have any of that. I did have one bicuspid that sat on the middle foramen and I told the patient before treatment – we discussed risk versus benefit, and the patient wanted to do it. They came back and they had some numbness in their lip, so what we did is we took an indelible pencil and we said can you feel that, can’t feel it. Can you feel that? I can feel it. Put a mark.
And we would map “couldn’t feel it, could feel it” the area, took a picture of it, and then have them back in a week and do the same thing and you’re finding the zones getting smaller and smaller and at one month recall, the patient had none, zero. But sometimes you’ll know that, but that’s more of a conversation of how you kindly and thoughtfully and reflectively tell patients about alternatives to that treatment because they may not want to take the risk.
Okay, I did want to go back to something that you had suggested earlier and it makes me wonder. In American universities the dental students are using CBCT because obviously you practiced for decades without CBCT. Now I’m wondering if they’re using CBCT in their residency programs so that they’re used to it so they think it’s actually necessary when they start a practice to have that.
Well that’s a tremendous point you just made, and I’ll flip it to you back to microscopes. When I started using microscopes in the mid-80’s I was the first microscope user on the west coast in Endodontics, and there were no books, there were no articles, there were no courses to be taken. And so it was trial and error and the blind leading the blind, and indignities that come from inefficiencies until finally you begin, you know, the 10,000 hours, and you get – you work towards mastery.
So, back to your question about the kids in school, I noticed when I went back to the programs over the years now they had microscopes. I’m talking about the graduate programs. This isn’t 100 students, undergraduates. This would be post-grad endo. Microscopes basically in every bay in every operatory. Well of course when kids get out, they go set up their office if they don’t – if they’re not going to go and be an associate or become a partner, if they’re going to set up their office, they’re going to equip it much like their experience in grad school.
They’re going to have microscopes, they’re going to have CBCT because that’s considered if I’m going to practice and call myself an endodontist, I got to play with the big boys and the big ladies. I’ve got to have what they have. So, you’ll replicate that.
It’s what they know.
Yeah, well because what you have described to me it sounds like a lot of the younger clinicians believe it is necessary and then I guess if you’re older and you’ve been practicing for a long time and you’ve been predictably successful and you haven’t been using CBCT, then maybe you don’t have as big an argument why that it is necessary.
Yes, I would never try to defend that you don’t need a CBCT. Hear me loud and clear. It’s always about the patient, stupid. So, think about if you’re that patient, stand in their shoes, do you think you could benefit diagnostically and success-wise towards taking a scan? Take it. No problem. But just be aware there’s radiation. And then there’s cost, and then, of course, we don’t see soft tissue. That would be the three things. We don’t see the distinction between hard and soft tissues.
Yeah, and I guess maybe the coaching might be don’t let the CBCT make up for your deficiencies in training, like still have a thorough knowledge of root canal anatomy and know the etiology of failure. What else? And just with experience, obviously that would, you know, improve your diagnostics a lot. And then if you have a good foundation there, then CBCT is great. Then it really helps you.
You know, something I should say, I think I can just do it right off extemporaneously. There’s been studies that have shown that you can find more periapical lesions 62 percent of the time. Well all of a sudden you’re going well maybe I should scan every case, but then let’s come back to what’s the chief complaint. What if the patient comes in, they can chew equally well left/right. They have no spontaneous pain. They have nothing that you could observe in your clinical exam that is suspicious, I’m not taking a CBCT.
But it’s different if they come in and they’re having some vague ache and pain and everything looks fine on a regular film, then I think you need to start thinking about what else do I have in my bag of tricks that could help me maybe make the diagnosis and be more clear to the patient why they’re here. So, I think that’s important. Sixty percent more missed canals, okay, 62 percent they could read more periapical lesions cause they were just like can’t see the periapical, scan, oh, there it is.
Missed canals are a big cause of failure, and so again, if you don’t know your anatomy you’re probably taking scans because you’re thinking, you know, I’ve got to find out there’s a fourth canal. I just always assumed there was a fourth canal, and we found them over 92 percent of the time clinically. Probably missed I few, didn’t I? So, I don’t really think we should – it sounds like maybe we’re having, you and I know this, we’re not having a debate about the virtues of CBCT or microscopes or NiTi, any of that stuff. We’re saying easier, better, and faster, treatment plan for no surprises, keep your patient in mind, that’s why you exist.
Yeah, we’re not saying that we believe it’s a controversy of whether or not you should use CBCT. We’re saying there is one.
Not at all.
On the AAE Discussion Forum.
There’s a lot.
There’s two sides, and they seem to be warring.
Well, so one side is very indignant that getting everybody to take a CBCT on every presenting patient, they’re outraged by it.
Yeah, I think you actually kind of summed it up for me. You said, “Proponents say those who oppose it are cowboys operating blindly, and those against it say those who charge every patient for it are charlatans.” So, I – that seems like a pretty heated controversy. I think probably if you’re going to do it on every patient and have it be incorporated – have the cost be incorporated into your treatment fee so you’re not presenting the patient with an added cost that could be up to $400 that they weren’t thinking was going to a cost for them. So, maybe just include it into the whole treatment fee.
I think if we can incorporate a comprehensive fee, then we don’t surprise patients, because they hate to be surprised.
Okay, well that’s the segment. Next time we’ll talk about GentleWave, if GentleWave should be used on every patient. And, you know, again, we’re not trying to, you know, take a side ourselves. We’re just presenting the issue and then we got some of the ideas and we used from you. So, thank you.
SEGMENT 2: Post Removal with the PRS
Welcome to a little show on removing posts. Previously we’ve talked about post removal in the context of the ultrasonic option. And that’s always going to be your first option, let’s face it. You want to get a post out, let’s get our piezoelectric out, let’s see if we can vibrate and knock that post out. But that doesn’t always work in my experience. It will work dominantly, but not each and every time. So, we need to have fallback positions so in the event we can’t get out the post with the ultrasonic option, we have a fallback position.
So, today I’ll talk about the post removal system. And if we look at it just quickly, and then I’ll go through it in quite a bit of detail. But basically we have some trephines, we have some taps, and we’re going to grab the top of the post, we’re going to secure it with a tap and then we’re going to use the extracting plier and by turning this knob, we’re going to get those arms to open up. One arm will push down the tooth, the other arm will pull up the post itself, and it’s like taking a cork out of a bottle of wine. So, if you’ve taken a cork out of a bottle of wine, you already kind of understand the mechanics of what we need.
Okay, so we have a little kit here, and it’s pretty simple. It looks complicated, stay with me, don’t panic. All right. So, take posts out for a lot of reasons, and of course, the obvious one, the tooth has been previously treated endodontically. It got a post, post-treatment, and now the tooth might be failing later in time. So, we take posts out frequently in the failure situation where we need to revise the tooth and push it back towards healing and long-term success.
However, many general dentists report to me – Cliff, I think it’s fine endodontically, and I might even check it and say it is fine endodontically. But they need to put a post in because the post that’s there doesn’t meet the current restorative requirements. So, sometimes you want the post out just for restorative reasons. So, those are two common reasons for the restorative reason and when there is endodontic failure.
All right, so we have the parallel post. It’s one of the most frequently used posts, and so you’ll see a lot of peri-type posts out there and different metals and build ups, and start thinking about getting back into these teeth. You’re going to have to maybe take the crown off. Sometimes you’ll work through the crown. Those are clinical decisions.
Then there’s going to be a core, some kind of a buildup probably in the pulp chamber. You’re going to have to be prepared to remove all the buildup materials. They could be cements. They could be composites and they could be amalgam alloy, and those are tough to get those all dissected out to liberate and free the head of the post, but we must expose the full length of the post all the way down to the orifice that it goes down into.
So, you have the easiest post to tap would be the cast gold post. So, we have a Para Post, okay, we have a cast gold post and we have the threaded post, the screw post, and in fact, this is the most retentive post. Flexi-post is an example of a threaded type of post. So, they’re the most retentive posts in the business, but they’re also the one that oftentimes is linked to the radicular fracture. So, be careful threading things into a root that you could overcome the root’s resistance to fracture, and you may actually crack a root. So, those are three commonly used posts, and they’re ones we see in the marketplace.
The posts have different head configurations; some are Christmas tree like. They’re all for retention of the core itself, so those are going to be things we take out. So, let’s come back to the post removal system and we’ll look at it a little bit closer. First take your transmetal bur, and the transmetal bur is nothing more than you use to cut access cavities through amalgams, non-precious metals and precious metals. But you can use that transmetal bur, move the handpiece in an orbital arc above the post transmetal pivot point, and you’ll dome it. And once you have it domed, that’s going to help the other devices from inside the kit get centered on the top of that post so you don’t skip off, okay? So you got a dome. That takes like about 10 to 15 seconds.
Now once you have the post domed, you need to machine that post down, and you need to machine it down according to these different diameters. So, the small trephine on the far left is 6/10ths of a millimeter. And then we have a trephine 2, a trephine 3, 4 and 5, and you can read their cross-sectional diameters, but when you use these trephines, you’re going to machine the post down very, very precisely.
When you machine a post down, try not to, you know, come out this way and then come out this way and then in and out of the primary beam. Try to be like a drill press where and it comes right down, right down and stays centered and aligned with the long axis of that post. That will give you your greatest success. We don’t oftentimes use the 1 and the 2. This is more for grabbing a carrier-based obturator, okay? Like Thermafil or something like that. It also can grab a silverpoint. Let’s make it easy. It can grab anything that’s bigger than 6/10th of a millimeter.
And a lot of times things that extend sub-orifice level up into the pulp chamber, are bigger than 6/10th, so if you’re having trouble trying to get it out, rather than break it needlessly and foreshorten like a carrier, why don’t we just tap it and then we have a way to grab it and pull it out. So, the 1 and the 2 – I think I moved that a little bit, the number 1 trephine and the number 2 trephine are primarily not for posts, because if you machine down a post to these cross-sectional dimensions right in here, the part of the post that’s sticking up now is very machined down.
And when we go to use torque with these taps to thread it on, we could shear off the head of the post inside the lumen of the tap, and then you don’t want that. But you get bigger dimensions out here with the 3 and the 4 and the 5 and those are the ones that will handle most posts. In general, if you’re really kind of in a question cause this is a short, little segment, it’s not too complicated, try the big one first. I always do, even with experience, and if it just sloppily drops over the post and it’s too big, go to the 4. 4 goes over, it’s too easy. Go to the 3.
By coming down sequentially, large to smaller diameters, you’ll find the one that won’t go over, and the one that just won’t go over is the one to use. Okay, so you have these various trephines, and then we’ll try the big one, like I just said, it’s too big. We’ll try the next one, it’s too big, so we’ll finally find one that won’t jump over the head of the post, and in this case, it’s the 3-striper, it’s the 3-striper, the 3 trephine. It’s got sawtooth configuration blades. That’s going to help you machine down these posts. These posts can be really, really hard metals. They could be soft like gold, but they need to be machined down.
And if you know anything about machine shop 101, we must keep things cool. So, we can use a viscous chelator like Glide, ProLube, RCPrep, and you can just put a little bead or drop on top and that would be like going to a machine shop anywhere in the world where they use oil and oil not only keeps the teeth of the trephine sharper longer, but it also keeps the heat reduced so you don’t internally build up heat. When you build up heat, you actually work harden the post and you make it more difficult to machine down. Okay, so now we can come right in here and we have our 3 spinning in a low speed handpiece. It should be able to develop about 15,000 rpm, in other words, it needs to have good torque.
I like the cable handpiece particularly well. It has good torque, and it can machine that post down. You’re going to machine the post down about 3 millimeters to be optimum, but sometimes you only can drill down about 2, because the post could be broken off way down low and just a little bit sticking up above an orifice. I want to say one more thing about machining down the head of the post. It’s called cap drilling. Okay, peck drilling, peck, lift it up, peck go a little bit deeper, lift it up.
When you go over metal on metal, you’ll hear the rpms start to decrease. You’ll hear that whine start to fall off. Lift the drill up, let the rpms pick back up so you’re running about 15,000 like I just said. By peck drilling, you don’t try to machine too rapidly, you don’t dull your trephine and you don’t weld the trephine to the head of the post. Colleagues have done that. So, peck drilling keeps things cool, keeps the blade sharp and lets you continue your procedure.
Now typically, if you use the 3 trephine you would pick the 3 tap. The tap is probably 3, 4, 5,000th of an inch, smaller than the trephine, so it won’t just jump over it. You can see there’s an important little well right here. In other words, the first thread is actually up in the lumen about a half to three-quarters of a millimeter. That’s so when you bring this over it can sit on the domed part of that post so it doesn’t slip off. So, you have the first thread is intentionally a little bit up into the lumen.
Well you have a neural handle. You’re going to be pressing really firm down so we have this beveled edge. The beveled edge is going to allow comfort as your fingers push apically and you do these little, short, clockwise – okay, counterclockwise. We’re going to turn this thing counterclockwise because that will also take out the screw post. It will have a left-handed thread, so we made this kit with everything in mind, parallel post, gold post, threaded post. There’s an arrow here; you can see it better in the real kit, but on the top of that arrow it has a definite little head so you can see which way to turn it.
I’ve had people call me on the phone, they’ll go, Cliff, I’ve been trying to get this tap to engage the post and I can’t do it. And after you’re talking a little bit, is it dull, is it old, did you ever get a new one? They’ve done all that. Which way are you turning it, Doctor? Oh, I forgot, it’s a counterclockwise rotation. Check! There is a port on these handles at, you know, two different ways you can go in here. And you’ve got a torque bar so the torque bar goes in the port and it can give you better leverage and mechanical advantage as you’re backing out a threaded post.
Okay, so now you know a little bit about how this is working. We have videos of this that are longer than this on the website and you can go look at things I’ve read and published, but this is a bumper, and the bumper needs to go on the tap before you start to engage the tap. This is your cushion. This is going to reduce the loads on these teeth. Let me say it. I have never vertically fractured a root in all the years and years and years I’ve been using the post removal system, decades. I have blown off porcelain, I have cracked sometimes a cusp off. These are all things you discuss with your patient, risk versus benefit.
Remember, if you can’t get the post out, what usually do you do? Maybe surgery if you can approach it or maybe the extraction of the tooth itself, and now you’re off to an implant restored situation or maybe you’re going to do a bridge if you have a posterior abutment, but you’re off to the stakes rapidly move up. So, talk to your patients, cause it’s pretty easy to repair porcelain or even to make a new casting if it saves the tooth and you can be successful endodontically in your retreatment. So, the cushion is important. It goes on.
We’re going to set this little well. We set – it has it’s first thread about a half a millimeter up inside. It’s going to sit right on top of this, right in here so it doesn’t slide off, and we’re going to engage the post with the tap. All right. So, do you remember that little comment about short, anti-rotational, boom, counterclockwise, short, don’t be doing this, you won’t get started. It’s push firm apically one push firm apically and take little, 45, 90 degree strokes and you’ll feel that tap start to go from wobbling to firm up and you’re starting to draw it down, and as you draw it down, the head of that post, you have a very secure connection.
Okay, so now you have your cap firmly secured on. I’ve gotten posts out by only tapping down maybe 1 millimeter. Remember we try to machine it down about 2 or 3 is ideal. You try to put the tap on 2 or 3 millimeters, that’s ideal, but sometimes I’m trying to convey here that you can only get down sometimes ½ millimeters and that’s all you need to just get a hold of that post and be able to draw it out. So, there we are.
Coming back to the kit, we’ll get out the extracting plier by spinning the knob. You’ll see these jaws begin to open up, and these jaws as they open up, they’ll be able to push a load down. This will push down on the tooth. This other one will be pulling up, okay, it will be pulling up on the post. So, there’s your device. So, you’re going to mount. So, I think I’ll pause this. This strap right here goes above the knob, this little outcropping right in here, there’s a little outcropping. It goes between the knob and the handle. I have this on there for a reason.
Not all of you use a rubber damn. If you use a rubber damn, you can take a hex nut, back this out and get this clip and just throw it away and simplify your device. But this was made for those cowboys who don’t use a rubber damn and we don’t want this apparatus to fall off and go into the oral pharynx where it could be aspirated or swallowed. So, that’s what that’s for. That will secure this to the extracting plier.
Okay, so back to the action. You’re going to start turning the handle, so you’re going to turn this handle, and it will open up very quickly, and then you’ll see your cushion begin to jockey. It will realign based on the height of the cusps; they’re various heights between cusps and among cusps. So, it will be a leveler. It will balance out, and we’ll stop again. But sometimes as you turn and you turn and you turn, you realize it's really starting to get hard. You know, you went from like this, fingers, to all of a sudden you see people in a workshop start to go like this, they need more leverage. Well that’s when you stop.
A sustained constant load on a retentive post, and I didn’t even go through all the various generations of cements that are used to loop these posts inside roots, but some of them are pretty formidable. So, if you come to the limit where you’re going from fingers to now you’re starting to use more fulcrum, break out your ultrasonics. Have your assistant run that vibrating tip in a piezoelectric unit up and down, up and down on the tap because that’s going to send a powerful wave of piezoelectric energy down through this post, down into the engagement, and you’re going to be able to start to overcome the retention of the post and the luting material to the dentinal walls. So, that’s an important concept. Don’t forget the power of indirect ultrasonics.
And you’ll notice kind of magically, they notice this in workshops all over the world, that all of a sudden it starts to turn quite easily and the colleague is usually thinking, oh it must have slipped off, it must have slipped off. But no, often times they’ll see attached to the end of the tap is the post you were trying to get out. So, that’s post removal. There’s lots of little nuances. We could have another whole session on this and talk about what if it does slip off.
Well I’ll just say it quickly. Go to the next smaller sequential trephine, drill it down again, the head of the post, use the correspondingly sized tubular tap and engage that, so we have other – we have fallback positions. We have other outs if we do fail, if we do strip off. That’s why you always start with the biggest one that won’t slide passively over the post. So, when you do find the right one, there’s usually one more chance below that. You could even use the 2. I said don’t use the 1 and the 2; they’re typically for silverpoints, carrier based obturators, things like that, but you can use them on some skinny posts that might be in an mandibular incisor.
Okay, so you’re out of there. So, the one comment is when you see these jaws start to get further and further apart, the first few millimeters of travel when you’re taking a post out, you’re on axis. Say on axis. The axes of removal are the axes of insertion, okay? So, you’re pulling on axis. That’s completely safe. But as those jaws go further and further and further apart, you’re beginning to make a circle. You’re beginning to get off axis, so and you see these jaws getting maybe a little uncomfortably far apart, you might consider this little trick.
So, I’ve talked about this little outcropping right here already. So, if we can put a second cushion, that brings the lower jaw and we put it now up in here, so now these jaws are much closer together. You can also go to a machine shop. I’m sorry, the company, SybronEndo, is too cheap – did everybody hear that part? – to include these. They cost like about 10 cents. If you go to a machine shop and you take the guy one of your taps and say can you make me a little donut that will fit over the end of that tap? I need spacers, can you make me a 1 millimeter shim? Can you make me a 2 millimeter shim? Can you make me a 3 millimeter shim?
Now between 1, 2 and 3, you have all kinds of combinations, so that’s what these are, but they’re not available in the kit, but that’s what I frequently use. I’ll show you how that looks. I have put in two shims and another one, two shims, and basically I brought these jaws right back together. They’re almost parallel. I’m pulling more on axes. That’s an important trick.
So, if the jaws get too far apart and you’re back here on your screw knob on the extracting plier and the jaws are getting wider and wider, I don’t like to tell you to do this, but close the jaws back down, take the mounting plier off, I hate to have you to take off the tap, so don’t. But we can slit, and I’ll show you this clinically, we can slit a washer, we can slit one of those right down the middle and we can slip it in and around, and then reengage by putting the extracting plier back on and now our jaws are closer together. That’s an important little trick.
Okay, let’s look at a case. So, we’ll go very quickly cause you’ve seen it, slow motion and animation, but people come in like this in the real world. They got a porcelain fused to metal crown. The colleague tried to drill in here to put a post. He started to reduce the silverpoint. You can start to see right in here there’s like a divot in the silverpoint. Well that’s where the guy that was using his post drill got off axes and started to – well he went from being on axes, the silverpoint itself, cause it’s run down the canal, to getting over here where we have root loss. We have a little shelf right here if you see that.
So, I’ll clear this out and you can look again. See there’s a little shelf right there. So, that’s just how it’s going to be. It’s going to be weaker there. Probably the silverpoint is going to break coming out. It will probably break right here, and so I’m going to be left with a split cone silverpoint and I have a right periapical lesion. So, I do need to get that little segment out or at least I could do surgery and push it back out, so it's good to take the crown off. The crown isn’t fitting that well, so let’s go.
Here we go. So, we’re getting our cement liberated. Notice that I’m using the transmetal bur and I’m machining down the head of that post because a lot of these post heads are a variety of configurations and of course your trephines will never go over them, so you got to use your transmetal bur to make it post-like. Critical, Ruddle didn’t go out here, and I didn’t go out here. In fact, I know in the back room there they’re going to say please, please, please, I need color.
Okay, so I did not go out here. I reduced the post down at its own expense, so I’m saving tooth structure. If you’re thinking about minimally invasive endodontics, you’re probably pretty excited that maybe we’ll save quite a bit of tooth structure, try to keep all the lateral dentin you can. Okay, so we’re peck drilling. You can kind of see me peck, peck, peck, peck. Keep your rpms up. You’re machining that down. When you push, the patient’s got to hold their head kind of still and try to resist the pressure, but you’ll machine it down quite perfectly.
And then here we are with the tap. So, I’m using the correspondingly sized tap, and I’m going counterclockwise, and you can see I’m drawing it down, I’m drawing it right down. Here’s the first stop. I’m slitting and putting a second stop. I’m putting a third one cause I want to keep those jaws close together, and as you turn that knob, the assistant can give you some ultrasound like I talked about. This is Panavia, one of the strongest cements in the business. Notice only a few threads, just a few threads. We didn’t get threads all the way along the whole trephine down, machine down post, only a few threads is the difference between success and failure.
So, basically, you got the post out and we won’t go through all the other things other than to say I’m using a bypass technique and this bypass technique is tedious. It takes a little bit of time, determination. Don’t say I’m impossible; say I’m possible, and just go past it. You can probably, if you look carefully, see the end of my file sticking out beyond the overextended silverpoint. Probably you can see that. We get that out, we do a little bit of revision and shape. You can see the patient’s come back with a new casting. They have a new post in.
The lesion that we can see is kind of like this to my eye and pretty close to the board. You can see we have a significant amount of bone fill, laterally, and right down – of course we’re not going to get attachment to gutta-percha and sealer, but that’s pretty good healing, and that’s about 10 years later. So, I think we’ll stop right now. I had a couple other cases to show you variations of the post system being used on patients of record, but I think you get the idea. Case selection, ultrasound. If you’re not going to be successful, you need a fallback position and it isn’t drill it out. You need to have an idea, and it could be the post removal system.
So, use your transmetal, dome it, then choose the biggest trephine possible that won’t just sloppily pass over the head of the post. Trephine, peck drill, don’t forget to peck drill, and then choose the correspondingly sized tap and tap on down, counterclockwise is the motion, and you’ll get a good, secure, bulldog attachment to the head of that post. The extracting plier can let you progressively jack that post out. Good luck on removing your post!
CLOSE: Influencers – Childhood Friends
All right, well, we have new close, and it’s called “Influencers.” And in this little close we’re going to talk about one thing in our lives or it could be a person, who has greatly influenced us. And my son Isaac pointed out to me that most people think of an influencer as someone from social media, so I looked up the definition. And actually that is the second definition. The first definition is “a person or thing that influences.” So, we’re using the word correctly.
So, we could talk about a number of things in this little close. If you look at the graphic, we could talk about life events, family friend, a piece of technology that’s really influenced our lives, a sport that’s impacted us, so there’s a trip, there’s lots of options. Today we’re going to start with a childhood friend who greatly influenced us. So, why don’t you start?
Well I spoke about Dr. Carl Rosich previously. He’s my brother-in-law, married to my sister. Anyway, Carl, I’m going back in time now. I was in the fifth, sixth and seventh grade, and during that time, he was the head of the gym, okay, so he ran the gymnasium. He had the key. Everything went through Carl. He was the big man on campus, and he was actually the tall man on campus.
And just a reminder to our viewers, cause we talked about Carl last time. I think he’s about five years older than you?
Yeah, I think he is about five years older than me. So, I was sixth, seventh and eighth grade. So, basically, I was pretty little and we had just moved from Seattle and he said well why don’t you come to the gym? Montana has long winters, nine months of snow, so the gym was a place, it was a safe haven. So, I got to start playing basketball, and I was awkward and all that stuff. Well then all of a sudden, he started organizing leagues and intramural sports and freshmen, sophomore, this is high school kids, I’m in grade school, so he finally said to me one day, why don’t you join us?
Well anyway, what I learned from that short experience is – well, it was over several years, but the experience I learned to really work hard. I learned that when you’re not good at something, practice, and when the game was over, guess who was in the gym, guess who sometimes would slip out the back door long after everybody left, and I was practicing. And I remember Carl used to say, work on your left hand, you know, use your left hand. So, I remember from – well nobody would choose me on their team to where lots of people wanted me on their team.
And so I think practicing, learning, learning how to win, learning how to lose, and those kinds of things are life events, and then being part of something that’s bigger than you, a team, those were really great experiences, and I think it actually shaped my life across all my life.
Yeah, it kind of reminds me a little bit of the book that we often refer to on the show, Outliers where there’s an opportunity that seems to come into someone’s life and they take advantage of it. Like how great was it that Carl had a key to the gym!
So, that was like a big influence for you. For me, I often think about her, my friend in grade school, Shanda Kammerer.
And she lived in our neighborhood, too, and one thing about Shanda is her father was Chet Kammerer and he was the basketball coach for the West Mount Warriors, which is one of our local universities. And during the summer, he ran basketball camps. And so, I would go to the basketball camp with Shanda and we did this a few times, and I have to say – say there was 50 kids, maybe three or four were girls.
So, you know, basketball isn’t my favorite sport, but I – Shanda was very athletic and I was kind of athletic, and so we really pushed each other athletically and sports was like something we really shared, so I remember going to basketball camp with her and just having to play with the boys and feeling a little bit like inferior skill level and just having to like push myself to, you know, be accepted and play with them.
And one thing I think about this, and I think about you playing up, too, when you were playing with the older kids, is that when you do that, you’re kind of uncomfortable, but you really – you push yourself to be better, and you know, it might be a little scary, but it, you know, puts you in a situation where you become better. And then another thing about Shanda’s family is that they also ran the concession stand there for the – cause for the games, and so sometimes I’d help her run the concession stand and that was kind of my first experience like, you know, handling money and paying and giving change and stuff.
Yeah. So, that was kind of neat, but yeah, I think that maybe if you’re a dentist or an endodontist, like we talked about how we hung out with the older kids and it pushed us to be better, like maybe you, you know, if you hang out with successful clinicians, you’ll learn from them, you know, you might raise your game and, you know, learn some things. So, there’s a lot to be said for hanging out with someone that you feel is maybe a little superior to you in one way because you could learn a lot from them.
Oh yeah, that’s the very essence of dentistry. If you go back to its roots, no pun intended, there were many mentors that would – people would sit at their feet, if you will, and they would learn in the 40’s, the 50’s, the 60’s and then study clubs and all that, so yeah, model success. Success leaves clues.
Okay, that’s a great quote. So, thank you to Shanda Kammerer who I have not been able to find anywhere on social media to this day, but who’s still very prominent in my mind, and thank you to Carl Rosich who we have recently discovered is your childhood hero. So, anyway, thank you for joining us for The Ruddle Show, and we’ll see you next time.
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.