One of the greatest advancements in the history of organized destistry was the introduction of the dental operating microscope (DOM)...
Microscope Tips & Perforation Management Q&A and Crestal & Furcal Perf Repair
This show opens with a new segment, “Top of the List”: Ruddle and Lisette reveal what is top on their lists for their next house projects. Then, Ruddle and Lisette do a Q&A, resulting in some helpful and simple microscope technique tips. Next, Ruddle is at the Board showing how to repair crestal and furcal perforations, because as Ruddle often says, “S*** happens.” Which brings us to the close of the show… Some more of those wise Ruddle One-Liners.
Show Content & Timecodes00:54 - INTRO: Top of the List – House Projects 05:38 - SEGMENT 1: Q&A – Microscope Technique Tips 14:18 - SEGMENT 2: Perforation Management – Crestal & Furcal Repair 51:56 - CLOSE: Ruddle One-Liners
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…I feel that my assistant and I are fumbling more while working together. Do you have any tips?
Yeah. Get rid of your assistant [laughs]…
INTRO: Top of the List – House Projects
Welcome to “The Ruddle Show.” I’m Lisette, and this is my dad, Cliff Ruddle.
All right. Glad to be with you again. There’s a lot going on out there, and here we are again to clarify, make some comments, and maybe sometimes even be controversial.
Okay. Well, the first – our opener, I hope, is not too controversial. We have a new opener, and it’s called “Top of the List,” and I think it’s pretty safe to say that most everyone is really busy nowadays with almost every aspect of their lives. And even when we do have free time, it can be pretty overwhelming to just choose a single activity to do. Or maybe there’s even something you want to buy, but you’re limited financially. So, the point of this segment is to identify what is at the top of the list regarding a certain aspect of our lives. And it could be a technology addition to your office, it could be a new food you want to try, or even a vacation destination. But today we’re going to talk about house projects. As you can see, “House Projects.”
So, what is at the top of your list regarding a house project?
Well, sometimes what arrives at the top of the list is due to urgency [laughs].
Well, that’s gonna be mine [laughs].
Okay. What’s at the top of the list? I think since 46 years, I’ve had a little histological lab inside my – I think in Europe, you say the “operatory,” or you say the “surgery,” and here in the United States, we say the practice. But I’ve had a little histo – two-man histo lab there, and I’ve had it for many, many decades, and I’m going to move it closer to home. And closer to home means the property that we’re on now is adjacent to where I live. So, about 15, 20 steps from here is a great little studio that we’re gonna convert, and that’s where my histo lab’s gonna be installed. So, that’s one project.
To get down to the house where we are now, and where the studio is, and the property itself, there is a narrow driveway, and it has been brought to my attention that the retaining wall is leaning a little bit.
So, we wanna make the driveway a little bit more accessible, so before we convert the studio, we probably be – oughta be able to get the lumber trucks and the concrete trucks and get them down the driveway, so we can actually pull off the whole situation.
So, that’s like two projects, but it sounds like they’re kinda interconnected.
Yeah. They’re interconnected, and they’re fun projects. And the histo lab is my little sanctuary. I’ve talked about it before, a little bit. But it’ll come home, and it’ll be a chance to just take a few steps that I can be trying different things. And when people drop by, we can go shoulder to shoulder, see what’s going on. So, it’s fun.
Okay. Well, for me, the top of my list regarding a house project has to do with my backyard. So, I have a swimming pool that’s surrounded by bricks, and there’s a very large tree nearby that has really big roots, and it’s pushing the bricks up all along the side of the pool. And I’m actually getting a little bit concerned that it actually might go right through the side of the pool. So, I think something needs to be done about this, sooner rather than later. And even though it might not be my first choice of a house project, it's maybe not the most rewarding thing for me, because I don’t really spend a lot of time in the backyard, I do feel that the urgency of the tree root-pool situation kinda puts that to the top of the list.
Well, I’d certainly be careful that you don’t stub your toe [laughs].
So, we thought, how do we go about getting these things done?
Well, how you get things done is through conversation. I’ve talked about this, too. It’s not so brainstorm – this is not an ethereal, but you need to have some goals and write them down --
We need Tony.
-- commit to them, and we need somebody to execute the plan. So, yeah. We have the goal, we have the plan. Now we have the timeline. So, now we’re waiting for the contractor to return from seeing his grandchildren in Colorado.
And that’s Tony, and he helps us with a lot of our house projects. And he’s been working on a very large project lately, for the past year, and he’s been kind of unavailable. So, I don’t know what we need to do, to get him on the show. I was thinking maybe even like bribe him with like a recurring segment, “Talking with Tony” maybe.
Oh, “Tony Talk”.
There you go, “Tony Talk.” And “Tony Talk” can then walk you through how to remodel and crisp up your office and how to make it look really nice, home projects, bricks can be laid flat again around the pool. All these things are in Tony’s world.
Okay. Tony, if you’re listening out there, we need you! Okay. We have a great show for you today. Let’s get started on it.
SEGMENT 1: Q&A – Microscope Technique Tips
All right. So, we have another Q&A to do for you today. And since recently, you lectured for the Academy of Microscope Enhanced Dentistry, microscopes are fresh on your mind, and we’ve had some questions come in related to the microscope. So, this Q&A is going to be sort of revolving around tips for using the microscope and just other – all things microscope related.
And it might be actually pretty much addressed to the AMED audience that has those questions. [laughs]
Okay. So, the first question is this. It’s a two-part question. I’ll read both parts, but maybe I’ll remind you of the second part if you forget it [laughs] while you’re answering the first part. Okay. So, the question is, what brand of microscope do you currently recommend and why? What is the first question you ask a rep when looking to buy a microscope?
Okay. This actually came up in San Diego. I’ve had several microscopes, which is not answering your question. But I’ve had probably four or five different models, completely different companies. In 1990, more or less, ’89, ’90, I went with Global. And I had the -- Global’s 5 step changer for one decade. And then, in 1999, I got a Zeiss, and I had the first PROergo in North America. And I’ve had this one since, so that’s about 20-some years. So, I’ve had Global and Zeiss. But when I’ve traveled overseas, I have frequently been exposed to microscopes like Leica or like Seiler – Seiler.
So, those I would say internationally are the four most popular scopes, and I think what you choose to use is up to your second question, and that’s more related to after-sale service. So, you can have a superb microscope, as you know, but if you can’t get somebody out to ask a question, it’s not always that there’s a technical problem or that your scope is broken, it’s sometimes you might want to add something to it like a camera, a monitor, and now you need tech people to help you put all this system together. Storing data, retrieving data, sending data to colleagues, a lot of it depends on after-service sales [sic]. And I have thought Global is a superb after-service sales [sic] company.
Okay. All right. The next question is, I recently purchased a microscope and have had some limited experience using it because I have tried it in several – several times in hands-on courses, not microscope hands-on courses. I think they mean that they just tried it and --
It’s been there for a course.
-- because – right. So, since I am not a total beginner, do you still recommend a microscope course?
You’re actually a total beginner [stage whisper].
You’re actually really, really new. You’re a beginner [stage whisper]. In other words, if I heard the question right, and I saw the question when it came in, I went to a course to work on – name it, Procedure A. And at the course, they happened to have a microscope, and I pulled it over, and I could do Procedure A with the microscope. That’s not a microscope course. That’s a scope on – a course that could be on cleaning and shaping, on packing, on removing broken instruments, repairing perforations, that we just talked about. It could be a lot of courses, and they happen to have a microscope, which benefits your ability to see and your ability to perform. But that’s not really all the nuances.
So, I would say, if we’re talking about where do you go to train --
-- I was just at AMED. I don’t wanna pound that to death. That’s the Academy of Microscope Enhanced Dentistry. They have an Annual Meeting, and they have vendors there. And there were all kinds of vendors out in the big ballroom, and there are a lot of courses. One of them is the Newport Coast Oral Facial Institute. That’s Sheets, Paquette, and Wu. Those three women have been in microscopes for decades. They give actual fundamental, basic, elementary courses on how to get started using the microscope, chair positioning, patient positioning, doctor assistant positioning, how do you hand things under the objective lens, the little nuances that make the doctor start to take off and fly. So, that’s a good one.
Johnny West, my pal for 40-some years, he gives courses at IDEA. That’s the Interdisciplinary Dental Education Academy. They are in the San Francisco Bay area, and they give specific – I don’t think John does, although John has microscopes for his courses. That was your earlier question. So, you could be going there to learn about endodontics and use a microscope, but they actually – I saw in the program, they have basic, elementary courses on how to start using a microscope. You need to learn and get professional training because it’ll set the stage for faster growth. You’ll be able to do things quicker.
You won’t be like me back in the ‘80s, trying to fumble your way along until finally you figure it out. So, I would just say, get professional training.
Yeah. To use a Ruddle one-liner, which we’ll do at the end of our show today, but --
-- but one of them that we’re not gonna do, but I know is one you always say is, “You don’t know what you don’t know.” So --
-- you might think you have a little bit of microscope knowledge, but you don’t know what you don’t know [laughs].
Oh, yeah. In life, there’s the things you know, there’s the things you don’t know. And the things that really worry Lisette and I are the things you don’t know you don’t know.
All right. The – we’re a little bit limited on time, but I think we have time for one more. And whatever we don’t get to today, in I think about two shows, we’re gonna do a Part 2 Q&A on microscope questions. So --
We get them all the time, don’t we?
-- yeah. So, this is – don’t worry if we don’t get to your question today. Hopefully, we’ll get it – to it coming soon. All right. So, the next question is, with the new microscope our office recently acquired, I feel that my assistant and I are fumbling more while working together. Do you have any tips?
Yeah. Get rid of your assistant. [laughs]
No, fire yourself and replace yourself with a microscope user! The reason you’re having upsets is because it’s normal. When you do anything new for the first time in your life, there will be many indignities, many upsets, and you’ll have gone from like efficiency and proficiency to like all of a sudden groveling around, fumbling to do the most basic thing. That’s basically two questions ago. Go get trained and take your assistant with you.
Oh, okay. So, is that --
Take your assistant with you. You can’t come home and regurgitate two days to your chairside. My God! Put your arm around her, get her a plane ticket, and take her to the course! And you’ll work together! And can you imagine, over those two days, how you’ll evolve? And when you go home, it’s kinda like, yeah. You have a lot of training still to do, but those endless repetitions always bring it in.
All right. When we were discussing this before the show, you had told me something about – like a tip about passing maybe under the objective lens. What – like passing instruments, what was that?
Yeah. So – so, here’s the microscope.
And I’m sitting here looking at it, and you might be looking at a monitor, but things have to get – and then, here’s the patient’s head, their nose, their mouth. So, you have a little bit of room in here to pass things in. Well, if you’re passing a file in, there’s lots and lots of room! But if you’re passing in like an Obtura gun or a Spartan – you know, something bigger, bigger armamentarium, it’s easy to hit [laughs] the lens, or you could even brush the patient’s face a little bit, you know, and they don’t like that.
So, you gotta tell them, when they do that, my assistant, she used to box. She’s in there with her gold gloves, and she likes to make light contact, because that’s when she knows she’s right with – no, I’m kidding you! If you believe that, you’ll believe anything. Go take a microscope course.
All right. Well, I think that’s actually all the time we have for today, but we do have a lot more questions. I think we have about six, seven, eight more questions. So, we’ll get to those in a couple shows.
Okay. In the meantime, never give up.
SEGMENT 2: Perforation Management – Crestal & Furcal Repair
All right. Today I’d like to talk about perforation management. And of course, we talk about perforation management, there’s several things we should kind of clarify. First of all, perforations can occur because of iatrogenic things, events, like a drill or a file or a probe or something like that. But certainly, just to be complete, we can have carious lesions, and carious lesions can perforate and create problems with restorability. And then, of course, we have pathological problems. And we can have pathological problems like internal and external resorptions. So, those can also be in the family of perforation management and especially when we talk about crestal and furcal repair.
So, we have at least three etiological factors that can contribute to crestal and furcal repairs. And then, of course, I wanna talk a little bit about a few other things. Where is the perforation? So, we speak about location. Location is a huge item, because if you look at roots, and you divide them sort of into thirds, and – thirds, is it a coronal, is it a middle one third, or is it an apical one third defect that we’re trying to address? In general, the more apical the perforations, the better the success, the better the prognosis. Because we can always go in, as an example, surgically and take off the apical third of the root. We start to worry about crown-root ratio and problems if we get into the middle one third, but we can still hopefully have enough root left to retain it.
But it’s the crestal perforations, especially the iatrogenic ones and the carious ones and the resorptive ones, that are really the problem because of combined endo-perio lesions. So, those are a little bit of things to think about location. I would like to talk about the second variable would be size. You know that the area of a perforation could be described as A = π r 2. That means if we go and curve from a 2 round burr to a 4 round burr, we have actually increased the surface area to seal by 4 times, because it’s an exponential relationship. So, perfs make a difference on their size.
And then, of course, there’s rounder ones that go right through the furcal floor of a tooth, and they’re usually done with a burr, so they’re rounder. Whereas the ones that occur on the sides of roots, by nature of occurrence, they can be ovoid. What’s the point? It’s tough enough to seal A = π r 2. And to the extent they get oblong and ovoid, the surface area is enormous. So, it’s gonna take a good material and good grip control and good management to get that repair material in there and get it sealed so you can have an optimal biological attachment, if that’s at all possible.
So, we talked about the level, we talked about size, and we’ll talk about location. Location of a perf is not so important in nonsurgical intervention. If you’re talking surgery, it’s huge. Whether the perf is on the buccal, facial, whether it’s back behind and it’s on the lingual, whether it’s proximal, it all depends on where it is, and can you approach it technically without destroying so much bone that it doesn’t justify the procedure. So, level, location, size, and the last factor is time. In general, repair the perforation the day it occurs. It’ll never be more ideal. That’s assuming it’s a fresh perf, that’s assuming Ruddle did it. So, it’s iatrogenic, and it’s a mechanical perf, probably. So, everything’s pretty clean, isn’t it? Oh, yes. Everything’s pretty clean.
So, if you think about the chronicity and how time intervenes, and all of a sudden you have leakage, and now you lose the attachment, now you have a combined endo-perio problem. And so, from internally, we really don’t care if it’s buccal or lingual, mesial or distal. But we certainly care a lot about that location if it’s a surgical approach. So, that’s a little bit about perf repairs. I have written chapters in textbooks around the world, and this is described in pages and pages, what I just said in a few minutes. So, let’s get going.
If you look at this case right here, obviously, this is a perforation secondary to a dentist chasing for the elusive canal that has now become so mineralized that it’s pinched out vitality, and we have a frank apical lesion. So, the dentist is trying to do a root canal, to eliminate the root canal as a source of irritation to the attachment apparatus. In the process, you would think, if you look at what I’m seeing, you might see a hint of something right in there, right in there, if we do these arrows. They’re bigger – way bigger than the canal, but you see a hint, just a little hint, almost nothing. So, we’re trying to line up, find the canal, negotiate it, shape it, clean it, and fill it. And then, we would expect the lesion to repair perfectly. Right? That’s Endo 101.
But when we make an access, it seems like our tools should be appropriate for the space we’re trying to use them in. And when I start to see perforations of this size, I’m thinking somebody was using road construction, like a road grader. Maybe it’s a skip hoe or a backhoe or a front loader. They’re trying to go in with the wrong tool. And then, of course, we didn’t stop at any time during the procedure, when we were a little uncomfortable, and we were not sure where we were. That’s signal number one, stop, take a film. Maybe even remove the rubber dam so you don’t have the clamp to obstruct your vision. And carefully work your way down.
Obviously, if you had CBCT, you can line up even better. But even in two-dimensional photography, there’s many, many things you can see from this case and learn, not to be critical of others, because we’ve all probably had a perforation from time to time. But it should be rare and infrequent, and when it does occur, we should try to repair it immediately. Immediately, so we don’t lose attachment, we don’t start having a combined endo-period problem. So, normally, when we have a perforation repair, they can happen in a lot of different ways. I would say access is probably the most common, iatrogenic perforation in the coronal one third of a root or in a furca, because the furcation a lot of times has multiple canals and has multiple roots. And so, dentists are looking.
And a lot of these teeth, you know, the pulps shrink down, they pull away from the occlusal surface or the carious lesion. And now, the filling that was placed, there’s more recession, there’s more mineralization, there’s more calcification. All these things together give us a little bit of problem. So, I’m not gonna go through all the things, but take your pre-operative films. They should be – you should be using a rim kit, aiming devices so you get good one-to-one images, CBC can come aboard.
Frankly, I love CBCT. I think it’s as important as the microscope. I’ve said that many, many times. But I didn’t have CBCT during all the decades that I was practicing, and I can tell you, you can do an awful lot if you know your anatomy, if you’re careful, and if you use the appropriate size drill to get into the tooth. It’s okay to stop and check, where am I? Do I need to shift a little bit, facial, lingual, buccal, ling- -- okay. All those different adjustments are what bring the case in to a successful conclusion.
So, the problem with the perf as most of you know, it’s an upset, and you’re trying to find the canals. And now what do you do? So, most dentists immediately put in a cotton pellet. They wedge something above that, and then they put in a provisional. And I’m making this all up. It isn’t true. But they go home, and they scratch their head. What should I do? Then, they crack out some old manuals that they had from dental school 50 years ago. Oh, there’s not so much information here. Well, then, they get online. They have a cell phone. They go, let’s get online. Let’s see what people are doing around the world with perf repairs.
The point is, time intervenes, and at some point, as time intervenes, and you have a really dirty environment with a lot of inflammatory cells, you lose the attachment. And now, Sharpey’s fibers disengaged, they’re not attached to the surrounding cementum, and you start to have a probeable pocket, and now we have a combined lesion. And that’s when the colleague goes, you know, maybe I can refer this. Maybe there’s somebody that handles these things and knows what to do. So, the point is, when a perf happens, either you repair it immediately that day, while they’re in the chair and anesthetized, or you get them to somebody you work with – okay – because they’ll know what to do, and they’ve seen that before. And if you don’t have somebody close by, then, if you’re doing endo, you should be trained up so you have a few ideas in your bag of tricks, so you can overcome an upset.
So, when you lose attachment, we now have another kind of a problem, don’t we? We must speak, ask the question. The problem is, with chronicity, you have more and more bone loss, and all of a sudden, if you go to pack something in here to get it sealed, it can tend to go everywhere, everywhere. So, years and years ago, we learned about CollaCote. And CollaCote is a really, really good resorbable barrier. So, if you read my textbook chapters and things like that, you’ll notice that we categorize barriers as resorbable and non-resorbable.
But CollaCote, CollaPlug, CollaTape, they’re all collagen in a matrix, and they can be cut in appropriate little sizes, and they can be introduced and stuffed through the defect. They can be stuffed through the defect and into a three-wall osseous defect. If you’re putting this into soft tissue, it’s just gonna puff up like a balloon, like you’re blowing up a balloon, because there’s no three-wall osseous defect. So, you need to be putting CollaCote, little pieces of it, pack it through, provoke bleeding. It’s a bloody environment, it’s an inflammatory environment. The pH isn’t so good. Remember, chronic leakage.
So, place the CollaCote through the defect, and keep packing it into the bone until you bring the CollaCote right up flush with the cavosurface of the root. Now you have a barrier. Now you can pack in against that barrier. So, a barrier gives us hemostasis, and it gives us a backstop to pack filling materials against. That’s the two reasons that you need a barrier. Now, if you’re using a barrier, probably the conversation should shift a little bit to, well, what is the repair material, because they kinda go hand in hand.
If you say you’re choosing CollaCote, I’m thinking you’re probably going to use MTA. And there’s lots of different kinds of MTA in the world, but it’s basically one of the tricalcium silicate cements, and it’s been used – introduced by Mahmoud Torabinejad of Loma Linda University, back in the ‘90s, the middle ‘90s. And so, there are hundreds and hundreds of papers that give us the credibility and the confidence to use MTA in these kinds of environments. So, if you’re gonna deal with moisture, you’re probably gonna use MTA, because it’s not so affected by impurities of the moisture, which could be blood byproducts in miniscule amounts – in miniscule amounts.
But if you have a bloody situation or something you can’t totally control, it’s probably MTA. If it’s MTA, then you need to have a barrier to pack against. And this barrier will resorb, and it’ll resorb in about four to six weeks – four to six weeks. That barrier material, that CollaCote plug that you put in there, it’ll be all gone. And if you’ve done everything right, and you’ve been able to get a good barrier, and you’ve been able to seal – seal the defect, and it’s really sealed, then you have confidence to go back and say, can I adjust my access? Can I find the MB, the ML, the DB, the DL? Can I find all the systems and appropriately shape them so that they can be cleaned and filled in all their dimensions?
So, if you think about MTA as your barrier, MTA is not packed. It’s vibrated. It’s activated with vibration, just like in construction. They use a vibrator to move concrete around rebar, which is steel, so we have a good, tight interface between the rebar and the concrete. No voids. In dental school, you did this, too. You forgot about it, though. You didn’t think about it. But in dental school, you vibrated dental stone into an impression model so that you could capture the intaglio of that impression, so you could get a good casting, right? So, you’re used to vibration. You’ve done it in dental school, and you’ve done it for decades since then.
But we can do that with our MTA. So, don’t pack MTA; vibrate it. It'll float into the defect. It’ll slump, it’ll adapt, and it’ll seal. And you can bring that MTA right up to the surface that you want, and then, you can go ahead, do your endodontics, as I mentioned, and you can repair the access cavity. And now, it’s down to, can we get reattachment? So, we’ll have the patient back typically in 30 days, and in 30 days, if you notice that it doesn’t probe, then go ahead, and you can signal to the general dentist, or you might be the general dentist, and you can go ahead and put the casting on the tooth because there’s a good indication radiographically that biologically, you’re repairing.
So, things are going in the right direction. It makes sense, then, to invest more dollars – dental dollars – into that tooth, because a casting is going to protect the tooth from a subsequent fracture. And that would be devastating to have a perforation and a fracture because we’re sitting around not sure what to do. In another segment, I’ll have the team right now make a note, we will talk about banding and building up teeth. I’ve seen a lot about this on the Forum. Apparently, they don’t know what a copper band is. Apparently, the ideas are so new, and with adhesion dentistry, we can skip some steps.
But wait a minute. If you got a cracked tooth and you’re trying to prevent a cracked tooth, there’s nothing like a core buildup with a Unitek ortho band to hold all that together until the dentist can intervene and do the dentistry. So, that’s just a little bit about it. You can put the casting on, as you can – have more confidence. And I have repaired many, many coronal and crestal perforations. Again, the perforations that come right through the floor of the tooth, they’re pretty round. They pretty much can follow the area of a circle, A = π r 2. When you have these, they’re gonna be very ovoid and long, and they’re gonna be much bigger than a circle. So, you’re gonna have to seal a lot more surface area. So, we need a great material, and that would be MTA.
All right. I got three cases. And how much time do I have? Just a little bit of time. I could talk about this, literally – okay [laughs]. This 20-minute, 25-minute segment, it could be an all-morning lecture, and Ruddle would be just about half done! Because I’ve talked about it around the world all day on perforations. So, here’s my pre-op. The history is simple. The patient had trauma. They broke both teeth off, pretty much at the gum line, and the dentist did a root canal. So, we had – first treatment was general practitioner did treatment on both central incisors. This would be number eight in American nomenclature. You can’t see that. This would be number eight, and this would be number nine, eight and nine, or one, one, if you like that. One, one.
You can see, then, after the root canal was done, the dentist put in a post in both teeth. But this post prep was out the side of the tooth, and you can see, we have pre-operatively a lesion of endodontic origin. And yes, it is crestally positioned. And it’s gonna be more ovoid by nature of occurrence. Well, all of this failed, and they went to a specialist. They went to an endodontist to have endo surgery. So, the endodontist whacked off the end of the roots, did the apicoectomy and did a root end prep and tried to do a root end seal.
So, this was the prep, and this was the seal. Well, it doesn’t even look like this retrograde is remotely in the end of the root, does it? It looks like it’s a floater. And there is, in fact, something going on apically. And then, of course, here we don’t see so much pathology apically. I’m pretty close to the board, but maybe if I get back, not so much. But look at the internal obturation. It’s like spaghetti! See this, Italiano! Okay. That looks like we’re having pasta for dinner! And it’s not even tight and on the plate. It’s like all over the place. It’s loose, it’s floaters.
So, that’s my pre-op. What are you going to do? Are you gonna sit there and talk with the patient and find out what they might want to do, because you’re talking two teeth. Can you take one out and do a bridge? Do you take them both out and do an implant? Do you take them both out and prep – you know, lateral incisors and canines and have a 6-unit bridge in there on a 23-year-old woman with a high lip line? A high lip line. So, you can begin to see, there’s quite a few things to think about, and there’s a lot of considerations, and there is a lot that the patient needs to be involved with, with co-treatment planning and co-diagnosis and what do they want, and what is the general dentist doing?
Do we need new crowns, and what about the posts? So, we decided to treat it, because after we went over all the various options, including the prognosis, the time, and the expense of all those things I just mentioned, it was pretty easy and brought us back to, what if we could save these teeth for 5 to 10 years? That would be a great service for a 23-year-old woman. So, that’s what we did. So, I requested that the general dentist remove the crowns for me and provisionalize, so that on the second visit -- the first working visit, the second visit, the second time I’ve met this patient -- I will remove two resin crowns, and I’ll have complete access.
So, here’s the big threaded post. You can see it. And we’re in there with ultrasonics, eliminating it. If you look right down in here, you can see the septum between what? The perf and where the post was. So, the post was over here against the gutta-percha. You can see, right in here’s the gutta-percha level, post-gutta-percha interface. And you can see, we’re looking right down in there with a microscope. So, obviously, you need good vision. And vision is not just magnification, everybody. Vision means lighting plus magnification.
So, with that visibility, now we can begin to look at the perf itself. And you’re looking right to the cavosurface after I’ve gotten some hemostasis. Hemostasis. Okay. Don’t use ferric sulfates. They’re powerful – they’re powerful hemostatics, but they leave a black coagulum that can help grow bacteria. So, even though it’s really good, we’re not going to be able to curette when we’re done, to eliminate the coagulum to stimulate fresh bleeding. So, we have to have other hemostatics in mind, like calcium sulfate will give us the tamponade effect, like CollaCote, which will crush the bleeders and pack it in so it can’t bleed. There’s many other kinds of hemostatics.
So, right now, I can see I have good hemostasis, but this is granulomatous tissue. When I pack something into it or vibrate something into it, I’ll push it everywhere. I’ll push it into the three-wall defect. I’ll fill the whole defect, right? So, let’s think about what we’re gonna use. Now, this was before MTA. This was a case in the ‘80s. First, I want to find out, where is the consistent drying point? You can use films, and you can put a metal object through the perf, and you can measure that by calibration. You can use an electronic apex locator. You might say, I have almost, Cliff, the chance to have direct vision, because I’m right here and right here, and I’m just looking down into here. But it’s a different level here than it is on the coronal side.
So, you need to maybe use a paper point. And I’ve talked about this for decades, but that part of the paper point that is clean, white, and dry is inside. It is inside the tooth. And the part that’s spotting red is beyond. It’s beyond the edge of the root. So, we can measure the paper point, the dry part, and we can know exactly where the cavosurface is. And I’m using CollaCote. Little pieces of collagen are cut in appropriate little squares. They’re carried in with a plier. They’re released in the defect, and then, a Schilder plugger is used to pack it through. It will provoke a lot of bleeding.
This is dried up again, for photography. That’s after many, many pieces, but it’s still not wall to wall. It’s still not tight. It's still not sealing. Its just a good start! A good start. And you can keep packing until you can move the patient’s head. So, in other words, it’s not a false barrier. It’s a real barrier, remember? A resorbable barrier will give us a backstop to pack against, and it’ll control bleeding. In this era, we were using EBA, ethylbenzoic acid. Okay? It was a material that came along, it was introduced by [Dr. Jose] Oynick and Oynick from Mexico City.
It’s in the literature, the period literature. He introduced it because Sharpey’s fibers could grow into it a few hundred microns. It was the first material that we had attachment leaving the amalgam era. So, we were leaving amalgam, and we were coming over to EBA, and we did not yet have MTA. We did not have the tricalcium silicate materials, the putties, the pastes, those kinds of materials. So, this was what almost all endodontists use. I never found it that hard to mix. I didn’t mix it. Ha, ha, ha, ha! The assistants mixed it.
But you train them and they mix it. But they really had to have that developed arm, that Nautilus arm, so they could feather that stuff out and get it into a nice, little pyramid that we can attach to the end of a Schilder plugger and deliver it right into the defect with great precision. And there is it, using a West trowel, a John West perf trowel. We could smooth it off perfectly with the intaglio of the tooth. And that was pretty much what we did on this particular case in that era. And so, you can see, we have a little nail head, perhaps just a little flash.
And here is our defect. You can see that I put the patient’s old post back in the tooth. And in this one, I left the post out, because I felt there was enough tooth structure with the circumferential ferrule effect that we would have no need to have a post in that tooth. I packed up against the old retrogrades. They were both loose. They weren’t even remotely associated with the end of the root except by geography, but not in terms of seal. So, Ruddle redid the endodontics. It’s hard to get hydraulics when your canals are pretty parallel. You know, you like to pack into resistance form, but we don’t have resistance form.
And to get resistance form, we’re gonna mutilate the tooth. So, you have to kind of take what the game gives you. And in this case, where a more parallel prep means we can’t get quite the hydraulics, but we can still warm rubber, get a little bit better hydraulics over here, and we have a little taper going, just a little taper, whereas over here, we’re pretty parallel. But we’ve got the perf sealed, and we got the system sealed. And the patient knows that future surgery is possible. We’re not gonna march to surgery. We’re not gonna schedule surgery. We’re gonna evaluate this patient and see how they do. I mean, what if they heal? What if everything closes down? What if we have attachment, no fistulas, no palpation? And then, what if the bone’s working? What if the bone is working? So, what if the bone is working?
So, here we are, out about three years, and you can see new crowns. This one did get a post, the number nine, the left one, left central. I’ve never gone back in. The patient seems to be comfortable. With all this excessive amount of material, this should be a lesson for all of us involved. Surplus after filling is irrelevant to the prognosis of the case. I’m not talking about proximity to the neurovascular bundle, the middle foramen, sinus, but I’m talking about in general. If we seal the tooth, surplus after with our biocompatible materials is really irrelevant, and it shouldn’t influence your decision to go back in and clean it up. You might make it worse. Okay?
So, there’s a little walkthrough on a perforation in the coronal one third of a maxillary central incisor and how Ruddle handled it in that era, with those materials. Let’s keep looking. Here’s the final kiss-off photograph. This is at about, I think, six months or a year, but we saw her out longer. But you can see the scar from the original surgery. You can see the original scar. This is just a photograph showing the two new crowns. The soft tissue could perhaps be a little bit better in here, with home care. But basically, you can see how pink and healthy and stippled the attached gingiva is, how everything was looking good. We’re even up to the lining of the mucosa. All right.
How about this case? We’ll just go a little bit quicker now. This case is sent into me, and it’s another big access. These are small teeth, and let’s make our access as appropriate for the size of the tooth that we’re entering. So, you can see, there’s a bunch of material here, and it doesn’t look like to me it’s associated with the canal at all. And if we slide it over and take an intraoral photograph, you can see that there’s big defect in here of the soft tissue. And if you palpate this, it kinda moves around, and I’m starting to recall that this is probably gutta-percha out there, and it’s probably been encapsulated by the soft tissue.
And now I have this big pedicle, this big pedicle of tissue, and the patient’s complaining about it. The tooth’s a little sore to pressure, but mainly they’re going like this, and do you see that, doctor? So, that’s what we have to look at. So, in this case, it’s a little bit different. The previous case was a nonsurgical repair. In this case, Ruddle just went back through the lingual access. There was a bunch of composite in here, and it’s kinda that radiolucent composite. So, it’s hard to make the distinction. Is it caries, is it -- whatever?
But I went down through that, found the canal, did the endodontics, and then I laid a flap. And when I laid a full thickness intrasulcular flap, and we’ve talked about that, you can see gutta-percha leaving the root. You can see a hole in here. You can see a hole where the gutta-percha’s not filling the defect perfectly. And you’re kind of wondering, how would you feel, and then you use a lateral cone, even use a lateral cone to condense around the primary cone, and both cones are not inside the root. Both cones are out in the bone, and you’re still packing. This is a good dentist. This dentist wants a good seal. Come on! If you believe that, you’ll believe anything! Who the Hell would ever do that and then act like everything’s fine?
I know it got quiet out there. If this was a big audience, you’d be – oh, you could hear a pin drop, because you’re going, God, was that the guy next to me? I wonder if the woman in front of me did that. Oh, it might’ve been the colleague behind me. They’re so young; they’re just out of school. But you see this stuff in everyday endodontics, and that’s when I realized there’s still a lot of teaching that needs to be done, because education guides us all forward together.
So, here it is. This is the laterally condensed cone and the master cone, not even in the root. This is Ruddle’s retreatment. This is Ruddle’s retrieval. That’s all external to the tooth. And then, I’ve done my repair. And in this case, we did a super EBA repair right here, and we did a super EBA retro prep up the long access. And then, if we let some time go by, you can see we can probe this quite vigorously. You can see the tissue’s even blanching, because it’s resisting the probe itself, because it has reattached. That’s fabulous news. Look how healthy that tissue is. And you can see it’s filling in apically and laterally, uneventful. So, that’s another kind of a surgical correction.
Again, timing is important, so we don’t lose attachment. I just keep pounding on that one, but it’s level, location, size, and time. Time, time, time. Don’t let it get chronic. And the last one, and I’m a little bit over. But you can see this colleague has made an opening right down through the furcation. You can see there’s a massive furcal lesion, and there’s an apical lesion as well. Now, this patient has a furcal lesion, and it’s a pretty round perf, because it’s by that round burr that made it right through the furcal floor. So, it’s pretty round. So, it’s less surface area. And we’ll take the bridge off, we’ll make sure we can find all the other canals, and there is the bleeding, throbbing perforation.
So, what are we gonna do? Again, what is the material you’re gonna use? Gotta think like this. And then, what is the barrier? If you’re going to use a bonded material, then you do not want CollaCote as a barrier. CollaCote will absorb liquids. So, if you’re using the principles of wet bonding, you’re gonna have contaminants, and those contaminants are going to affect the physical properties of the restorative material. So, in this case, we’re gonna use calcium sulfate. And calcium sulfate comes in the form of Capset. And I just lectured at AMED recently, few weeks ago, and I got to meet John Sottosanti. And John Sottosanti, who introduced me to calcium sulfate from the perio side – he’s a periodontist – and that was back in the mid-‘80s. And I’ve been using it and talking about it since.
And now, it’s become more of a mainline material in endodontics. But back then, it was a periodontal material. In endo, we didn’t know much about it. Nobody really talked about it. It was quiet, either didn’t know or didn’t understand it. But calcium sulfate is dental stone. It can be mixed with a liquid and a powder liquid, and you can put it in a microtube, and you’re gonna carry it through the defect and pack it out of the bone. It’s going to take about two to four weeks to resorb. So, it’s going to resorb, but what it does, it’s going to give you hemostasis and a barrier to pack against. Remember, a barrier to pack against.
So, we will overfill, recognizing it’ll resorb, even out of the tooth area, the furcal floor. But once it’s set up hard, we can use ultrasonics and “brrrr” it. You can go around and around and clean out the walls, so they’re nice and clean, and it’s dentin. And you can take it down to the floor of the furcation because that will all resorb away, and that’ll give you your barrier, though, that’s solid as stone to pack against. So, there we are with it all sanded back to the floor of the tooth, to the actual floor of the tooth, and we’re gonna be pushing a lot of stuff out in here. But then, we’ll now have a barrier to pack against. So, that’s pretty much how that works.
There I am, using a Geristore-type material. It could be a bonded material, it could be glass ionomer material. We’ve talked about these in different shows. Gordon Christensen’s talked about these materials. Marco Martignoni’s talked about different materials. They’re all right here, dual-cured materials, they can all be placed, they’re hit with light, and you have good – very good control of a fill, because you have stone. You sand it back, so there’s no blood contaminants. That’s what I’m talking about, there’s no bodily fluids that are gonna interfere with the physical properties.
And then, here is all that calcium sulfate. Here’s all that calcium sulfate. Okay? It’s all down in here in that big cloud. This is my composite, dual-cured material. And ladies and gentlemen, there’s your five-year recall. Notice that the furcation is tight; the bone and the architecture is superb. Notice that there is still our repair material because it doesn’t resorb. So, remember, barriers are based on the restorative. If you’re gonna use an MTA material, you need to have moisture on the external side to fulfill requirements.
For a hydraulic material, it needs moisture to set up. Sometimes you have to use a hot cotton pellet internally against the material, so it gets the moisture requirement. Then you can take out your pellet on the next visit, and if it doesn’t probe, you know, and doesn’t sink in, the material has set up, it’s become hard, then you know you have chosen a good barrier material, and it’ll resorb with time. And then, there’s your MTA. If you say, no, I wanted to use bonding, I wanna use one of the new composites, I want dual-cured, then you’re gonna use calcium sulfate, so you don’t have the blood contaminants.
I hope you’ve learned a little bit about perforation repair, whether it’s iatrogenic, carious, or pathologic, certainly we’ve talked about how to deal with those in the coronal one third of roots.
CLOSE: Ruddle One-Liners
All right. Well, we’re gonna close our show today with some more Ruddle One-Liners. It’s been awhile since we’ve done them. And it’s – what this is, is there’s some things that my dad says, one-liners, and sometimes they’re quotes. Sometimes they’re paraphrases of quotes. Sometimes they’re things you’ve thought of yourself or just some – something a friend might’ve said that sounded catchy to you. So, we’re not trying to put these out as things that are coming uniquely from his brain only, but they are things that he says a lot. If you hang around with him and you talk to him, probably a few of them will pop out during your conversation.
So, I’m gonna read some of them, and then you can just tell me what you mean by it or why you like it or whatever you wanna say about it. Okay?
All right. So, the first one is this. “If you must speak, ask a question.”
Oh, I like that one a lot. “If you must speak, ask a question” is an opportunity for the person that you’re talking to, to actually join the conversation. How about that?
So, you might think, well, what does that mean? And so, you can do this with your patients. So, if you’re a patient, so, I get to meet you for the first time, I could say, ‘How are you doing today?’
It’s great to have you in here. Are you glad to be here? [laughs]
You’re not afraid of your toothache, are you? [laughs]
And be sure to pay your bill. Won’t you?
So, you see, we – the English do this. In fact, Julian Webber, you know, he was on the show a while back. But the British always end things with a couple of words that ends in a question. And I didn’t get this from the British, but I did understand that years ago, when you see people, start asking questions, and they’ll open up, and they’ll start talking.
Or just speak however and just raise your voice at the end, like it’s a question [laughs].
Okay. All right. The next one is, “Who you are is where you were when.”
Oh, well, I like that one a lot. That one reminds me how much our upbringing, our environment that we were raised in, the schools we went to, the sports we played or didn’t play, high school, college, and it goes on and on, dental school, what you learned, what you left behind, what you kept and took on the journey to pack your bags for success. So, I think we can all look at our environment and our experiences, and you can begin to see that – why we have differences.
Yeah. I think this comes out a lot in conversation, when we’re kind of wondering why someone would do something like that, and then, I hear you say, “Well, who you are is who”– or what – what is it? “Who you are is where you were when.” [laughs]
“Who you are is where you were when.”
Okay. So, the next one. “The future is so bright you better wear shades.”
Well, I was on the back of a motorcycle in San Antonio, whizzing down the freeway. The driver was Phyllis’ family member. He was at the helm of the wheel of the two-wheel bicycle – motorcycle. And we had on our earphones, and he was playing that song by Timbuk , and that was the day before my AAE lecture, which was in Dallas. No, it was in San Antonio. And so, I was hearing that song. We were flying down the freeway, and it was a beautiful day, and the wind was blowing, not quite through our hair, because we had helmets on. But I liked it a lot, because I was thinking how we look at things is usually how they are. So, if you think the future is really bright, it’s probably gonna be really great, and you might even need a pair of sunglasses.
Okay. So, that one’s actually lyrics from a song.
Okay. The next one, “Irrigate, Recapitulate, Re-irrigate.”
Well, this is one that I made up a long time ago, because it kept people out of trouble [laughs], like Cliff Ruddle.
Every time Ruddle takes a file out of a tooth, whether it’s done a little work, a lot of work, a major amount of work, whether it’s been in the tooth for 5 seconds or 50 years, I always say, “Irrigate, recap, and re-irrigate.” And I say “irrigate” because that kicks out the gross debris, and “recapitulate” means take a small-sized stainless steel hand file or an EndoActivator, flexible polymer tip, and go back to length, and stir the soup and move all that debris into solution, so that when you re-irrigate, you liberate that debris. And I think if you irrigate, recap, and re-irrigate, oh, my God, endo just becomes so much more fun!
Okay. I think we have time for one more. The last one is, “Everything old is new again.”
Oh, let’s irrigate. Oh, what? Excuse me. [laughs]
“Everything old is new again.”
Well, if you look at endodontics, I mean, I’ll just pick on minimally invasive endodontics now, to even be controversial. But back in the ‘50s and the ‘60s, a little before I came into the game in the ‘70s, the preps were really, really skinny, and they were much like the silhouette of a silver point.
And you would look at those, and Schiller would talk about millimeters of wires traveling through underprepared canals that were neither shaped nor clean. But it looked white on a line, and the x-rays said there was a white line. So, everybody was, you know, a [clapping] round of applause. You know, almost no tooth structure was removed, and this little wire’s going through. Oh, it’s a thing of beauty! And then, they mostly all failed. And so, we spent the next 20, 30, 40 years digging them out.
So, I think “Everything old is new again” is the size of the prep is right back to where it used to be. We still have all the issues with cleaning that we had back then, because they were so small, how are you gonna clean them. We have new technology, so that’s good. And yeah. Everything kinda repeats itself in endo. There’s like trends.
And not only endo, just in life, too.
Oh, my goodness, yes.
Like everything’s kinda cyclic. Like fashion is always like going in cycles.
I mean, yesterday, didn’t Aaron Judge hit 62 homeruns? Everything old is new again because Maris did it in ’61. So, what’s the deal here?
Okay. Well, thank you for watching, and I hope you liked the show. See you next time on “The Ruddle Show.”
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.
DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at www.endoruddle.com/inventions.