Extra-Canal Invasive Resorption Special Case Report by Dr. Terry Pannkuk

This show opens with a frank discussion of dental learning… Are dental students and dentists receiving the right learning? Then – SURPRISE – we have Dr. Terry Pannkuk at the Board, after a brief introduction by Ruddle, presenting a case report on Extra-Canal Invasive Resorption (ECIR). Next, Ruddle and Lisette close out at the desk with a post-presentation discussion. The show concludes with another round of Ruddle Rant, this time targeting the AAE Discussion Forum, which tends to really get Ruddle’s blood boiling.

Show Content & Timecodes


00:57 - INTRO: "Right" Learning
06:49 - SEGMENT 1: ECIR Case Report by Dr. Terry Pannkuk
37:26 - SEGMENT 2: Post Presentation Discussion
46:55 - CLOSE: Ruddle Rant

Extra content referenced within show:

  • Special Guest: Dr. Terry Pannkuk
  • Levin RP: Are You Learning the Right Things? Dentistry Today, 7 March 2022, https://www.dentistrytoday.com/education-are-you-learning-the-right-things/
  • Dr. Pannkuk’s Educational Website - Pure Dental Learning (PDL): www.puredentallearning.com
  • PDL Webinar: “Severe External Resorption Treatment” (December 4, 2021): https://www.puredentallearning.com/webinars/2021-12-04/severe-external-resorption-treatment (Source of abridged case report featured on The Ruddle Show)
  • AAE Discussion Open Forum: https://connection.aae.org/communities/community-home


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    This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.

    OPENER

    Lisette

    …Okay, so the first thing is this – The necessity of reporting all of the technology you used when you post a case.

    Cliff

    I’m already upset…

    [music playing]

    INTRO: “Right” Learning

    Lisette

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

    Cliff

    Hi, how is everybody doing out there? I bet you’re ready for the show.

    Lisette

    Okay, well to start off today I came across a Dentistry Today news article recently, and the title caught my eye. It was called Are You Learning the Right Things? And it’s by a dentist name Roger P. Levin. And he is also the founder and CEO of Practice Management Consulting Firm. So, I see in the article, and in it, although apparently most dentists receive, in theory, an appropriate amount of clinical education in dental school and through ongoing CE, many dentists do not receive enough education in the areas of business, leadership, customer service, sales and marketing. So, do you find this to be true in your experience?

    Cliff

    I absolutely do. And this is obvious to everybody, but dentists maintain their licensure, the licenses, by taking Continuing Education, and most dentists that I’m aware of over decades of teaching, they’re pretty much staying in the clinical arena, and it’s kind of interesting because they go into tracts, like sometimes they’re doing an endo year. Sometimes it’s an implant year. Sometimes it’s a restorative year. But you hear them talk about more clinical courses than others.

    Lisette

    So, we talked about in a past show, just recently, how you had to take extra business classes.

    Cliff

    I did. In fact, I waited 10 years before I took my first one because I was always thinking the secret to success is to do better work. And of course, that can’t hurt, but on the other hand, I think you pointed out to me that I could have the best technology in the world, I could have the greatest training, I could have medals hanging all over my body, but if there was nary a patient, I’d be hard-pressed and accepting working on ivorine teeth, maybe. And then we did burnout too, you know.

    Lisette

    Right.

    Cliff

    I mean we talked about burnout, to manage burnout, burnout could be mitigated maybe in the office with new technologies and things you’re learning, but you could also step outside the office and exercise or something like that. So, those are in previous shows.

    Lisette

    Okay. Well in the article that I looked at, Levin suggested an 80/20 approach which means he was saying that you’re – about 80 percent of your ongoing CEs should be clinical and the other 20 percent should be more in the business realm.

    Cliff

    Business can’t be overemphasized. You know, you get really good with your management, cause you are the manager in the office unless you give it to somebody else to delegate it, but you are the leader, you’re the manager, you set the culture, you make the conditions, you’re trying to always enhance your service to your patients, and you’re always trying to – the team is trying to be the best they can be.

    So, with all that said, you still need to get the patient, attract them, and you still need to maintain and keep the patient. So, you can acquire a new patient, but did you keep the patient or did they go somewhere else? You got to make the service exceptional.

    Lisette

    Yeah, right, and do you agree with this 80/20 approach because maybe it depends on the person. Maybe some people might need even more.

    Cliff

    I think it’s doctor dependent. There’s that old expression, “In life who you are is where you were when.” So, not everybody that’s been out for five years from the same dental school is resourceful. So, I would think we should see those numbers change a little bit because I know they made big differences for me because when you go to those classes, you’re in there with other people just like you, and all of a sudden, you know, maybe your receptionist is talking to their receptionist and I’m talking doctor to doctor, maybe Phyllis is talking to somebody else and so all of a sudden, you’re learning more than just the instructors giving the course.

    But that’s a good way to keep your enthusiasm and joy and work on your service that you’re delivering to the patient.

    Lisette

    Okay. Well Levin did point out in the article, and I thought this was very interesting, that dentists who are well read and exposed to a variety of different topics and ideas tend to have excellent practices, and the idea behind this is that these individuals have a broader knowledge base and are better able to more creatively and strategically find solutions to problems that may arise.

    Cliff

    Well, that’s exactly why on the show, and I’m not – I’ll look right into my camera, this was not Ruddle’s idea, this was Lisette and Lori’s idea, that’s my daughters, and they wanted more balance. And I’ve really come to think that’s critical, because I can sit up here and go to the board permanently on Set B, and I could give you like 30-40 minute lectures and I could do that the rest of my life, but that wouldn’t be the best course.

    The best course would be to have adjunctive things on health and learning and new technology, innovations; that’s what rounds you out. And maybe we could even grow a few leaders, that would be the idea.

    Lisette

    Well, he closes out by saying that some of the most successful dentists he’s ever met tend to have a passion for ongoing education, and they tend to be just very curious, interested people who are constantly evolving throughout their lives. And when I read that, I’m like well that sounds like my dad, that sounds like you.

    Cliff

    Well I’ll just leave you with Mark Twain. I guess people have heard of Mark Twain. He was the Father of American Literature, but he said, “Don’t let your schooling interfere with your education.”

    Lisette

    Okay. Well, we have a great show for you today, so let’s get going.

    [music playing]

    SEGMENT 1: ECIR Case Report by Dr. Terry Pannkuk

    Cliff

    Welcome. Today I’m really excited, and I’m just delighted to announce our guest, Dr. Terry Pannkuk. He’s been on the show before, and he’s done some wonderful things in Santa Barbara for decades. Terry, as you probably already know, has Pure Dental Learning. You should be going over there too to augment your continuing education. I forget who said it, but somebody said, “You have no right other than to be a continuous student for life.” I was just kidding. G.V. Black.

    Okay, so Terry is more than just an endodontist, meticulous, consummate. He pushes the envelope and he’s always doing things years before we read about it in magazines. And it reminds me of a little glimpse of my career, and I’m so proud to have Terry here because he’s an innovator, he’s a very, very good thinker. We don’t have enough critical thinking.

    But more than any of that, he's my friend and my ex-beach volleyball player, and you can see when he gets over here, Terry, come on in. You can see why I wanted to work with Terry because he was very good at the net. Okay, so without any further ado, Terry, knock them alive.

    Pannkuk

    It’s a great pleasure and honor to be here today, Cliff. We have so much fun with our continuing education and it gives us a great opportunity to teach some interesting concepts and the latest techniques in endodontics today.

    So, today’s topic is the treatment of a complex extra canal invasive resorption case. This is an X-ray of the case we chose to treat. Many people would look at this case and say it’s untreatable. In fact, I just got back from the AAE meeting and there was a lecture by a very talented clinician and researcher who’s a PhD, Shanon Patel, and he spent the first hour and 15 minutes of the lecture categorizing and explaining the processes by which root absorption occur. The last 15 minutes he explained that even simpler cases than this are basically untreatable, should be monitored until they need to be extracted.

    I don’t believe that at all. We’ve been treating these for about eight years, and so I picked a case that Cliff and I could do a recorded, narrated demo on, and this was the case. Now the patient was a very motivated gentleman who presented with this very severe resorption defect which looks like it extends into the furcation with a little furcation breakdown, and extraction of this tooth would have been a huge problem because you take this tooth out and you have this pneumatize sinus coming almost to the osseus crest. The bone could collapse and you may only have less than a millimeter of vertical height bone for an implant placement without severe grafting.

    So, taking this tooth out was problematic, so the alternative option of extraction implant placement was not a very viable option. We decided to try and save this tooth, and I didn’t know if it would work because this is probably the most severe resorption case I had treated to date. Okay, here’s another off angle view, a bite-wing level view, of the resorption defect showing how extensive it is. Now at this point with the CT exam and here’s a CT exam. You can see there’s quite a crater in that lingual mesial portion of the root right there.

    And so, the structural integrity of this tooth is quite compromised, especially the palatal root, and you can also see a little perio defect in that area and another factor that affects the prognosis in this case is the fact there was about a six millimeter pocket on the mesial. So, if you have periodontal communication and a chronic resorption crater like that, large diameter crater, not a great prognosis. So, going into this case, I didn’t like the extraction implant option, but I really wasn’t really that crazy about the saving the tooth option either. So, we were in a little bit of a quandary.

    So, basically, I talked to the patient and said, if you’re willing to be a demo patient, I will do this case for free and we will try it for educational purposes and he was very highly motivated and thrilled to do it. I’m not sure he realized that he was signing up for a five-hour procedure, but we edited this five-hour procedure down to two hours for the demonstration, and for our event today, we edited and summarized it down to 22 minutes, so it was a much longer procedure than what we’re indicating by this program today.

    Here’s a pano view on another level, the transverse section, showing how large that crater was. So, we had our hands full with this case trying to treat it. So, we look at the CT scan. We look at it from each angle. We’re looking at how structurally compromised the different roots were. Huge bite into the palatal root. And so there’s a good chance we could treat this tooth, make this investment, have it restored, patient bites down on something hard, palatal root cracks and all bets are off, he loses the tooth.

    So, we’re going to go through in a few minutes, and we’re going to show the clinical process of treating this tooth and what our challenges were and how it went. Now it’s a two-step visit. So, the first visit the goal was to clean out, clean and shape the canals, address the resorption defect, treat that, gain control of the resorption defect, fill it with a bioactive material and then set up a second visit where it becomes a routine endodontic obturation case.

    Now, here’s the clinical beginning of this case. I use two clamps, the mesial clamp facing backwards so we have good isolation. The initial penetration is behind the MB cusp of this maxillary first molar. Now I’m swiping down palatally and mesially from the MB cusp and immediately there was profuse bleeding from the granulation tissue of the resorption defect, so I was placing trichloroacetic acid, which is a great hemostatic agent that doesn’t leave much of precipitant and it really controls the bleeding almost immediately.

    So, you can see the bleeding is stopping right in this area, right here, and we’re gaining control of the case with hemostasis so it allows us to visualize the anatomy. There’s the distal buccal canal, doing some initial shaping, still bleeding comes back, fit it with some more TCA, clean it out with sodium hypochlorite. I use full strength sodium hypochlorite, 8.25 percent, and use – make sure I vacuate it so it doesn’t leak. That’s why it’s important to have great rubber damn isolation with two clamps so you have this area isolated properly.

    Now this is a micro-suction tip, suction out of the canals. There’s the palatal, DB right there, and the MB. I’m using the EndoActivator to agitate some of the irrigant, and basically we’re just trying to clean and shape the canals, more shaping than cleaning at this point, and controlling the hemostasis from the resorption defect. Now at this point we’re placing the calcium hydroxide in the clean and shaped canals, and what I do is I mix up USP calcium hydroxide with some commercial paste to give it a consistency that can be expressed through a Centrex needle-tip syringe, inject it.

    This area right here is the resorption defect. This is the MB canal, DB over here, and the palatal is a little bit out of the screen underneath that lip of the tooth right there. So, what we’re doing is placing cavit balls. So, I put a small cavit ball on a Schilder number 10 plugger and I pack it in each one of the orifices. I’m doing that right there. I’m tapping it down so that we can seal the calcium hydroxide in the canal and then manage the resorption defect as we repair it.

    Here’s the introduction of the Biodentine. I typically will place one extra drop and then triturate the Biodentine and place it in a Centrex needle syringe and then inject it into the defect. This is what I’m doing here. You can see there is the Biodentine being injected through the Centrex syringe, and you can see we have the cavit ball sealing off the canals, palatal DB, MB right there. Give it a nice solid mix of the Biodentine filling up the entire pulp chamber. And then I just simply place Cavit over the axis right there. So, by tapping down the Cavit, I’m pushing the Biodentine even more aggressively out the crater of the defect.

    Now you can see right here I have a Woodsen and the Biodentine has been expressed out the side, you know, approximately out the large crater defect. I don’t mind an overfill, but the reason I am kind of tapping with the Woodsen is basically just to fill in the occlusal void that was in that area. So, here’s a Cavit ball, pack down. This is essentially the end of the first treatment visit. Take out the damn and you can see it was nicely sealed through the entire procedure. And we’re going to show you what our preoperative radiograph looks like right there. I’ll get a good pause point right here.

    Okay, let’s explain this. So, this is the calcium hydroxide and the palatal canal, a little bit of puff. This is not material. This is the sinus septum. That’s actually bone. This is all Biodentine, Cavit plug right there and there, and we filled the canal as best we could with the calcium hydroxide and most importantly, we compacted the Biodentine, filing in the crater in this area. And the Cavit temporary on top right here. So now we just wait. We send the patient home. There’s a more horizontal view showing the Cavit balls right there. Biodentine is compacted in this whole area here, and a Cavit temporary here. And so those are our two check films, and we’re ready to wait.

    And so we scheduled the check visit, and I’ll show you, here’s a view about a few weeks later after the procedure. This is the Cavit. This is kind of the rough, inflamed area where the defect was, and so we expect to have some inflammation. The gingiva is quite inflamed at this point, and this is about a two-month check visit later, and surprisingly we’re getting some healing in this area, minimal bleeding and the Cavit temporary and underlying Biodentine is nice and hard and sealing the root canal system.

    And what we noted when we scheduled the second visit was that the 6 millimeter pocket has shrunken to a 2, 3 millimeter pocket with very minimal inflammation. So, I was very surprised when the patient came back for a second visit. And even though it looked inflamed and very angry a few weeks after the initial visit, it looked fantastic with normal perio at the time of the second visit. So, this is remarkable. We were probing aggressively in that area, and there was very little inflammation.

    So, we’re getting ready for our second visit. It's a couple months later. Place a rubber damn on the same way, one wing faced towards the distal, and one on the posterior tooth behind the second molar, and then one with the wing, on the mesial on the bicuspid, and you can see – I was pleasantly surprised how nice the periodontal tissues look at this point.

    So, here we are removing the Cavit and we’re drilling into the very hard Biodentine. Biodentine has amazing physical properties that are superior to MTA and other bio-ceramic, bioactive materials. It has great compressive strength, pullout strength, compression similar to amalgam. So this is the material you can use. It’s bioactive will release hydroxyl ions and actually is as hard and has a structural integrity of amalgam.

    So, here we are, regaining access to the mesiobuccal one canal, MB2 is back there. The MB2 is kind of riddled with resorption, so we didn’t want to disrupt that too much. Awe relied on hydraulics filling that at the very end. But here we go. We have a really solid – let’s look at that. You can see we have a rock-solid Biodentine repair here. It’s not going anywhere. I didn’t want to press my luck and go into the adjoining MB1, the MB2 and pull that out and compromise the great seal we had and the great periodontal healing we had in that area. So, I decided to leave that. So now, it becomes a routine endodontic finish. And we’re going to show you that.

    So, we have a nice rock-solid void-free Biodentine repair of the defect, irrigating with sodium hypochlorite, cleaning it up. One other feature of trichloroacetic acid is it’s amazing at removing residual calcium hydroxide. So, if you want to completely eliminate the calcium hydroxide from the root canal system, use some TCA and that will dissolve the intracanal predicament.

    Here we are reestablishing patency, getting our final lengths, and I’ll show you the – and so we’re establishing our lengths with the – we’re getting our measurements at this point. That was 18 for the DB. And so, we’re just going through all these routine endodontics, getting our measurements using an Apex locator, finalize our measurements. So, we got out final measurements on each one of these. And I use a little bit of RC Prep as a conductant when I’m getting my measurements, works very well.

    And here we are drying the canals after fitting the – we’re going to fit the cones. And the amazing thing about using TC8, see no bleeding points. So, the canals are immaculately dry and not oozing any blood at the tip. You can see that’s a very nice blotting point right there. We’re checking our measurement to see where the blotting point is. There’s the palatal canal, and again, it’s not enflamed at all. We got nice, dry canals to obturate. We’re feeling very confident that can treat the case endodontically just fine.

    Paper point blotting of the DB canal. You don’t see any blood. You don’t see red tips after using TCA when you’re drying canals. So, we’re got an immaculately dry root canal system ready to be obturated. So, I use a final rinse of EDTA, 17 percent EDTA. I’m smoothing a few rough areas here. This is the final shaping before we fit the cones. I wanted to make sure there were absolutely no apical irregularities from the resorption defect, make sure we could slide a cone down to get tug back, and get an ideal cone fit. So, I went through that.

    Here my assistant is passing me the rotary files. And this just becomes a routine endodontic case at this point. We have the resorption defect repaired, we have complete control of the root canal system, and we’re just finishing up the clean and shaping. We’ll go through this. I use the ProTaper gold files here. Now we’re fitting cones to our length. So, the idea is to cut them back so you have smooth tug back without any crinkled cones and there’s the palatal canal with the cone fit, cutting it back two lengths.

    We want to make sure that it withdraws with tug back. That’s very important. I use these gutta percha gauges which are very precise in cutting back. Use a scalpel. I have my assistant cut the cone with the scalpel as I hold the cone through the – each one of these openings. And see that was 47. That was a 47 size. And we’re fitting these, each one – and I fit the cones wet so the canals are filled with sodium hypochlorite, and when you plunge a cone in a canal with sodium hypochlorite, it will spread the irrigant apically and gives you better cleaning. I think this is the final cone we’re fitting, checking the tug back, making sure it’s at length.

    This is the DB canal. So, I spend quite a bit of time fitting cones, and there’s my cone fit. I don’t think I need to make any adjustments. I may have cut – let’s look at this right there. I may have cut the mesiobuccal cone back just a hair, maybe an eighth of a millimeter. Adjust that. And I may have lengthened the DB canal a little bit. It looked slightly short as we blotted it and checked it. So, I cut back the DB. I added length to the DB and I cut back the MB slightly. Just recheck to make sure it’s perfect. So, I just want to emphasize how much time I spent cone-fitting. I think that’s a very important process of the endodontic procedure.

    Now before we fill the canals, rinse with 17 percent EDTA, activate it with the EndoActivator to disperse it. Then I use alcohol after using the EndoActivator to dry the canals and blot it with paper points, So, you can see we have great control of this case. There’s no bleeding. The Biodentine repair is rock solid, the periodontal tissues look excellent. They’re not inflamed, so we have control of this, what looked like a crazy case to treat.

    Here we go, final blotting. Yeah, it’s completely dry, no red tips. Now here we are placing the cone. I use Kerr’s sealer, regular set, so zinc oxide eugenol base sealer, and I use the traditional Schilder technique with multiple waves of condensation, so we use a touch and heat, remove a little bit of the gutta-percha, soften it coronally, pack it. So, we do at least five waves of condensation of heating and compacting the material so we get good apical deformation of the gutta-percha cone into the apex of the root.

    And this is just the process of obturation. And the fact that we have such great control and we have the defect repaired means we’re not going to have gutta-percha squirting out the side of the resorption crater. We solved that problem the first visit. So, the resorption defect was repaired the first visit so that we could perform a routine endodontic finish at the end. Here we go. So, at this point, you wouldn’t even know this was a complicated resorption case because you’re just treating it as a routine endo case.

    And so, the second visit was very relaxing. The first one was a little bit stressful with all the bleeding and trying to gain control, regain homeostasis. We didn’t have any of that the second visit. So, here’s a DB canal, same thing. So, I will usually pull the cone in and out just to make sure it’s completely coated without any naked spots on the cone, make sure it’s complete sealer coating. Almost routinely will – because my canal shapes are pretty routine, I use a 10 plugger to start, a 9 plugger down to a 1 or 2 waves and then I use an 8 plugger typically to do the apical packing by the fourth or five wave of condensation.

    And then I use the hotshot to backfill the root canal space with some pressure and hydraulics. And I put sealer on the hotshot tip when I’m expressing the gutta-percha to backfill. So, that’s apical condensation, kind of lean on it with steady pressure, usually about 6 to 8 seconds. And here we go, the coated hotshot tip and I’m expressing it back, just maintaining hydraulics and pressure to let it just backflow into the canal. Here’s the final canal, the palatal canal, being filled. Checking the coating of the cone, adding a little bit more sealer. I thought it was a little light. And we’ll show the down pack of that cone.

    It’s the same process as the other two canals, starting off with the 10 plugger, applying the touch and heat tip. It should be 312 degrees Centigrade and applied for 3 seconds if you want to match the original Goodman Schilder Aldridge studies to get the ideal flow of gutta-percha with the ideal rheology which is the heating characteristics of the gutta-percha to minimize shrinkage. And this is our result.

    Okay, so we checked our obturation with the check fill, and we’re happy with the way the fill looks. So, now we’re going to place the core. So, I’m removing the contact in this area right here. We’ll show you that. I’ll just go through that. This is going to be pretty quick. And basically, we just bonded a Photo Bond flexicore core in the access right on top of the Biodentine repair and the pulp chamber floor dentin and gutta- percha. So, there’s a free-floating matrix I use to place a core. There is the core bonded in place. You can see a little excess flexicore that I just simply carved away with a flame tip carbide burr.

    And so, this is our final film, and in conclusion, we have great Biodentine density, subgingival, sub-osseous. We have an excellent void-free flexicore core placed in the pocket and super gingival. I’ve instructed the general dentist to make sure the crown margin is high water of high coronal up in this area. You do not want your general dentist to restore these areas and try and chase the margin down onto the Biodentine repair. These heal just fine. The tissue reaction is fantastic, and if you can just convince your general dentist, restorative dentist, to keep these crown margins up high for coronal, you’ll have a great result.

    And interestingly, in summary, I’d like to say that I measure the outcome of all my cases, and I treat a lot of heroic routine endo cases, and my overall endodontic success rate is lower compared to my resorption aggressive resorption repair cases. So, and I think the reason is I have better control over the restoration at the end. And these are typically virgin teeth without cracks.

    So, to say that these teeth are untreatable is not true at all. These teeth are very treatable and should be considered for treatment. It’s a much better service for the patient to try and save these teeth than to extract them and replace them with implants.

    Cliff

    Wow, it took me a long time to come in from the outfield. Terry, that was just terrific.

    Pannkuk

    Thank you very much.

    Cliff

    Listen, you probably don’t realize what you just watched. This is multiple times I’ve seen it. I’ve seen it like probably five times, and every time I’ve seen this, I have learned something else, something a little more that I didn’t see my first time through or my second time through. So, I think the main point to say here is Terry does not expect, because the vast majority of people on the show today, there’s tens of thousands, some will be endodontists, but most are going to be general dentists. We don’t expect you to be doing this. This is not – Terry, this is not his first rodeo.

    Okay, he’s been doing this for years, and then he applies things that he learned earlier to help him grow, and then as he grows, the things he's learned that aren’t necessarily in the textbooks, can’t read them in a journal, can’t watch them on DVDs or play-throughs, he’s accumulating knowledge and information and he’s applying it to even more things. So, I think this is terrific. I’m so proud and honored to have you on the set. You were over there last time, but now we have you actually doing what you do, and that’s practicing and teaching and giving back. So, thanks so much.

    Pannkuk

    It was a pleasure, Cliff, and it’s wonderful to be here.

    Cliff

    Come again; don’t be a stranger.

    Pannkuk

    I will.

    SEGMENT 2: Post-Presentation Discussion

    Lisette

    Okay, so a big thank you to Dr. Pannkuk for that presentation. I think I speak for both of us that we are very appreciative that Dr. Pannkuk could put together that presentation for The Ruddle Show because it was I think about four hours of footage edited down to 20 minutes, so that must have been challenging. Why don’t you share with our viewers how it all went down originally.

    Cliff

    Well, it always takes a little effort to get something good, right? So, Terry did that case, it is my understanding it was two, two-plus hour procedures, so maybe five hours in total, and then, you know, I’ve done this a lot myself, so then you have to crush it down, and the reason he crushed it down is he has an educational center himself called Pure Dental Learning. And so, he wanted me to come over to his office, which I’ve done several times, and just be on the show when he reaches out to his international audience.

    Lisette

    Like a webinar format?

    Cliff

    It’s a webinar format, and dentists pay a fee and they can join, and he has quite a little audience that he has put together. So, anyway, he crushed down the more or less five hours to about one hour and 15 minutes. Well, when he was all done and we were just talking behind the scenes, I said, “Terry, I want you on The Ruddle Show, and that’s the good news; now do you want to hear the bad news?” And he said, “What’s the bad news?” And I said, “Now you’re going to go from one hour and 15 minutes to 25 minutes.”

    So, it makes you realize that you can edit things down that way, and it’s much better for you, because there’s a lot of flashing, waving of arms, things doing their own thing, you know, things get out of control, and you maybe got to reinforce the block. This is all dead time. You’re not learning anything. So, he did that, and so here he was today, and he was taking a very really long procedure. Everybody saw the second part, it was clean, shape and pack, it was perfect.

    The first part was the hero part because that’s getting the case to where it’s manageable, and then it becomes a routine case. So something you could learn is take something that’s very complex, put a little bit of effort towards it and then it becomes a routine case. So, that was something I really appreciate him doing that, because it’s hard to edit, and then when you think it’s pretty tight, and then you need to knock off 25 percent more.

    Lisette

    So, when you – so, when he did the webinar, I understand from something you said that there was questions coming in from his viewers live during the webinar, correct?

    Cliff

    This is – he has the software capability – we’d have to talk to your son, my grandson, the guy that would know how all this works, but while we were – while he was giving his narration, questions from all over the world would just come right in, and they’d be typed and laid right in, one, two, three, and you could see their names and the country. So, sometimes other people commented and answered another colleague’s question, so it was interactive like that.

    Sometimes Terry answered the question, sometimes he threw one at me and said, “What do you think, Cliff?” or “Would you have done it differently?” So, it was a really – it was like grad school, where we’d have 10 people in the room, there’s five in each class at Harvard, and then there would be the mentors, the teachers. So, we’d all go around starting with the first year, how would you do it, how would you do it, how would you do it, how would you do it?

    And then finally, the second year with one more year under their belt, well they would do it a little different, and then finally, the instructors would weigh in with their experience and then finally, Al Krakow would say, “Well, how I would really do it” – there would always be a hole in his shirt and something like that, and we couldn’t even believe he couldn’t buy a shirt without a hole in it. So, we’d be laughing hysterically, but covering up our laughs quite well.

    Lisette

    Yeah, I think at some point we’d like to do something like that on The Ruddle Show, like have the questions come in live while we’re filming, and I know that there’s some discussion about that, maybe being in the works for the summer, but we’ll see.

    Cliff

    I think Lori is working with that guy over in Thailand, they’re doing the software as we speak, and I think we’re going to be able to talk live back and forth. You might have to stay up in the middle of the night in your country to talk to me, but you know, it’s worth a sleepless night, right?

    Lisette

    So, if I asked you to point out a couple of things from the presentation that you found particularly interesting, what would you say would be?

    Cliff

    Well number one, I thought it was really excellent how there was the word “interdisciplinary treatment.” There was a general dentist, there was an orthodontist, there was an oral surgeon, there was a periodontist, and Terry. So, right off the bat, we have an example of the best of best, but everybody throws their hat in the ring and we hear from everybody, and we decided it’s not a bridge, it’s not an implant, because he had that dipping sinus that came almost to the crest, so then they ended up, well maybe weighing risk versus benefit, we can do it the way they did it. So, I like that.

    I liked the CBCT walk-through. If we’re talking sports, that was the walk-through. He told us exactly what he saw and he’s already rehearsing in his mind the steps he will need to take to carry out the procedures he envisions. So, I thought that was great. Then I noticed there was a few pull-back shots, and we saw a team, and with a case like that, you can’t just have a chairside. You can on the second visit, because you just clean, shape and pack. But you notice when he really needed all hands on board he had the hands there to do six-handed dentistry. So, I like that.

    And then, of course, I think the world got a pretty good glimpse of how TCA would be better than ferric sulfate as an example. I talked about ferric sulfate as a hemostatic back in the 80s, terrific, but this was almost no residual coagulum, powerful, but what he didn’t get to tell you because I made him go down to 25 minutes, it can be used every single day, TCA, trichloroacetic acid, can be used every single day to negotiate canals. What it does with vital cases, it shrinks collagenous tissue, it makes space for the file to get into, and it’s remarkable how TCA can help colleagues negotiate canals.

    I like Biodentine. You know, in the old days, it would have been MTA, one of those tricalcium silicates that we talked about forever. But then Biodentine gave us better handling and physical characteristics, and you could see how he packed it in there. And then he had a little thing in his breast pocket, I don’t know if you saw it, but he had like three references to share with the audience, and I said don’t worry about it, they can look it up, they can Google, they can do this themselves, but there is a lot of research on Biodentine, and it is a wonderful material, has characteristics after it sets as good as amalgam in terms of durability.

    So, when he talked about putting the crown on and keeping the general dentist not chasing that margin to the crest, making a high water margin crown, no problems. So, I need to tell the audience the tooth has been restored with a casting. He said if he would have had – okay, Terry just went to the AAE meeting, so he was gone for a few days, and then he just got back and here he is on the set.

    So, he wants to update it, he wants the world to know there’s now a definitive crown on it, and he’s going to have him back in about six months. It’s been about six months since he got the crown, and there will be another six months and he’ll want to do all the documentation on the recall. But right now, everything is looking great.

    Lisette

    Okay, well I just wanted to close out for my part telling the audience that I’ve had three root canals and Dr. Pannkuk has done all three of them, and if I had to use one word to summarize my treatment, it would be “thorough,” because he explained everything so clearly to me at the beginning with realistic expectations. There was documentation throughout my treatment, which was pretty much exemplary, like the documentation. He went over even some of the stuff with me afterwards.

    Then also, I just really felt the whole time that he was really caring about what he was doing, that he was doing his best possible for me, and that he was very skilled and knowledgeable with what he was doing. So, if I ever needed another root canal, and I hope I don’t, but it’s a no-brainer for me to go back to him.

    Cliff

    Yeah, I think I agree wholeheartedly. He’s been my endodontist too, and he is a fabulous person retreating other endodontist work, as you know. So, I would say then, maybe for me in closing, it was a tough case, and I don’t think Lisette and I sit there and we’re expecting now everybody to go out and find that case and look at their radiographic library of images and get that patient scheduled, we’re going to go in and do it.

    No, I think what we were trying to show you was that you should be part of an interdisciplinary team and you should look at these cases and get second opinions and third and through all the discussions, the patient is going to get the best treatment, and that’s what I think would be my closing remarks, and not that you’d know how to do it, but you know it’s possible.

    Lisette

    Yes. All right, well thank you, Dr. Pannkuk, and I guess now we have our close.

    Cliff

    Thanks, Terry.

    CLOSE: Ruddle Rant

    Lisette

    All right, we’re going to close our show today with another Ruddle Rant, and how this works is I say a topic and then you have one minute to rant about it, and then when the sand runs out, you need to stop.

    Cliff

    Oh.

    Lisette

    So, for this Ruddle Rant, we’re going to focus on something that tends to get your blood boiling every day, and that’s because you start off your day reading the AAE discussion forums.

    Cliff

    At 5:30.

    Lisette

    So, we’re going to talk about some topics you’ve read recently, probably like within the last week, probably this morning. Okay, so the first thing is this. The necessity of reporting all of the technology you used when you post a case.

    Cliff

    I’m already upset. Okay, so you do a case, right, and you’re really proud of it, and you show the pre-op, you show photos and you show the post-op. Did you ever say, “I was assisted with the overhead light, I had a doctor stool, it was performed with the Adak chair, and I wore pants and they were Levi-Straus, and you know, I had an assistant, and she was fully clothed,” and I mean, why do we do that?

    I mean there’s always this rambling thing, I used an Edge Pro Laser, blah, blah, blah, case by GentleWave, blah, blah, blah, blah. Oh, we CBCT’d it. Come on, guys, there are normal tools, your average tools, things that all of us can have and use and do use, so it’s not remarkable that you used a laser unless you’re trying to tell the world there’s some kind of superiority with how I’m doing my work. Am I done yet? Oh, I have a last –

    Lisette

    Oh, you’re done.

    Cliff

    Oh, I’m done. I was just getting warmed up.

    Lisette

    Okay. The next topic is the attempt to normalize bleeding caused by GentleWave.

    Cliff

    Okay, so I practiced, what, almost 50 years now? And I had how many bleeding incidences? I mean literally if you’re going into resorption case, you expect a lot of bleeding. If you’re going into a vital, inflamed case, you expect a lot of bleeding. But you don’t expect routine bleeding all the time. And then I see post after post, get over it, bleeding it normal!

    And then what I really don’t like is they have all the bleeding, they tell you how all the tricks they do and the hemostatics they use to arrest bleeding, and then they go back and do their shaping and they don’t go back and do the second GentleWave cycle, so are they not aware their files are creating mud? This mud gets pushed into a cocktail of red blood cells and smush, and it’s in the lateral branches, and oh my God, and then they’re not following up with GentleWave, so they use GentleWave sometimes early to avoid bleeding. Then they can do over shaping later with less bleeding. And of course, we’re now instrument 2 millimeter short, we keep the foramen really, really small, so we get –

    Lisette

    Okay.

    Cliff

    And once again, I could write a book, not just a chapter, and not an article.

    Lisette

    Okay, take a deep breath and here’s the last topic. A recent claim by a clinician who will remain unnamed that the lateral anatomy maybe isn’t so important.

    Cliff

    Oh, that’s ridiculous! I can’t even believe anybody would say that. I’m sure it’s a child of God out there, but you know, did they go to endo school? Did anybody realize that 90 percent of my practice for 40-some years was retreating other people’s work? Do you know we picked up 2.9 portals of exit for every single shaped canal?

    So, when you say it doesn’t work, you know, this is a person with sight, but no vision. This is a person who’s not been in the real world practicing. Lateral anatomy matters! I had a whole practice of it. So, this person, the lateral anatomy – well if the lateral canals don’t matter, why are you even doing the mother canal? Why don’t you just stay four short, five short, why don’t you do a deep pulpotomy? Why don’t you just pretend you did it and go bill anyway? I don’t know. Maybe you don’t like lateral anatomy. I know you said that the lateral canals are filled with cement and – oh, we’re done.

    Lisette

    Okay, that was our show for today. Thank you. That was the biggest rant I’ve seen yet so –

    Cliff

    Well I just hate to get so upset with the AAE discussion forum, but can we please use a little of the knowledge that’s been around for the last 60, 70 years and try to get better as a profession instead of trying to say – oh, I’m off on another rant. Instead of trying to say lateral anatomy doesn’t matter, be sloppy, that’s it, be the best endo you can be, but just do part of it.

    Lisette

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

    [music playing]

    END

    Disclaimer

    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.

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    03.03.2022 Update

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    Timelapse

    The Ruddle Show
    Season 8

    Release Date Show Get Notified
    10/12/22
    Endo/Perio & Recent Article
    Crestal/Furcal Defects & ProTaper Ultimate
    10/19/22
    WaveOne Gold
    Special Guest Presentation by Dr. Julian Webber
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    11/16/22
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    Trending Topics & Common Endo/Restorative Mishaps
    11/23/22
    To be determined - Check back soon!
    11/30/22
    To be determined - Check back soon!
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