Much has changed in global endodontics over the past 40 years and a great deal of this change has been driven by the relentless introduction of new technology...
AAE & Endo/Perio Considerations Annual Meeting & Root Amp, Hemisections & Implants, Oh My!
What to wear? What to wear? This show opens with a behind-the-scenes glimpse into choosing outfits for The Ruddle Show. Next, with the AAE annual meeting coming up, Ruddle and Lisette highlight some topics and speakers of interest. Then, Ruddle is at the Board lecturing about important endo/perio considerations, specifically root amps, hemisections, and implants. The show concludes with another installment of Aesop’s Fables and Endodontics; insert some more of that morality into your endodontics!
Show Content & Timecodes00:46 - INTRO: The Ruddle Show Wardrobe 05:22 - SEGMENT 1: Annual AAE Meeting 28:08 - SEGMENT 2: Endo/Perio Considerations – Root Amps, Hemisections & Implants 51:45 - CLOSE: Aesop’s Fables & Endodontics
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A volcanic eruption best characterizes endodontic treatment in recent years. This massive, upward thrust of clinical activity can largely be attributed to general dentists and specialists who are better trained. This evolving story is dependent on...
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…Well, I'm wondering if this is really meant to be a helpful debate or if it's more just like a exercise in cleverness. Do you think that there exists a reality where you would go to this debate and come away thinking, you know, maybe patency isn't so necessary?...
INTRO: The Ruddle Show Wardrobe
Welcome to The Ruddle Show. I'm Lisette, and this is my dad, Cliff Ruddle.
How you doing out there? I hope everybody's dressed as good as we are.
I think you look really nice today. Did you pick that outfit out yourself?
[laughs] Well, I kind of already knew the answer to that. So, Lori, my sister, The Ruddle Show Producer, the Website Manager, she is also in charge of picking out what my dad wears every week for The Ruddle Show. And just if you were wondering, my mom is in charge of his hair, and she has been for the past 50 years.
So, how we go about choosing what we're gonna wear is, I first pick out what I'm gonna wear, usually the day before the shoot, and then I take a picture of it, and I send it to Lori so she can have it in her mind and start thinking about it. Then, when I show up on the day of the shoot, she has me kinda stand back by where she has your clothes. And then, she kinda picks out what she thinks coordinates well. And then what happens?
Well, I obediently put it on. How about that?
No, the great news is I don't even have to think about this. So I just come over in California flip-flops, and I wear my Santa Barbara outfit, which is pretty much casual, casual. And when I get over here, I'm -- got a few sport coats to choose from, and they're
-- she chooses them, but there's a few sport coats, shirts and ties, and she does all this matching. Probably the neat thing she does is she takes a picture of us, and it goes into a wardrobe binder, and wouldn't you know, we know what we've been wearing for all across the shows. So, that's kinda how it works. So, she knows what I like, and she helps me be comfortable, because if I'm comfortable I'm fantastic!
Yeah. I guess I try to put my things -- my clothes together in a way that I haven't done before so that I have a kind of a new look every time. But you know, we -- we're shooting our 80th show today. So, it's been challenging to come up with 80 kind of different combinations or looks.
But I have tried my best. So, do you have any wardrobe preferences that need to be taken into consideration when she's picking out your outfit or, like, maybe you have a color that you love or maybe there's colors that you would never wanna wear?
Well, starting with the road trips, which I did for decades, all over the world, it just seemed appropriate to meet people in other countries and to look professional. So, I always wore a sports coat or a suit or something to lecture -- to go to the lecture. As soon as I got on stage, if you know me well, and when I go to Set B, which is right over here -- we're on Set A -- I take the coat off, because I kinda wanted it to feel like a grad school environment where, you know, you're -- you got your students around you and you take off your coat, roll up your sleeves, and we're all sharing information together.
Well, I notice that you wear purple, and you wear burgundies, and I've even seen you wear pinks. But I don't normally see you wear like a really bright, vivid orange or red. Is it that you don't like that color?
No, those are reserved for my underwear.
[laughs] Okay. Well, I know I actually once bought you a red shirt and it was given [laughs] back to be returned. So [laughs] --
Well, red in some tie, you know, a little bit of orange and red, I -- I didn't wanna wear orange because I didn't want the people from Tennessee to think I was a Volunteer.
Well, as -- Lori, she -- she will sometimes recommend that I wear a certain color if she has something in mind for you that she wants you to wear, but I'm just not picking -- what I'm picking is not leading her to that choice. So, she might recommend what color I wear next time. She'll tell me if I'm wearing the same color several weeks in a row. I do have some personal rules for myself, like I -- I want to be a little more formal and conservative than I am in my daily dress. A lot of times I just walk around, like, with sports bras and leggings. But I try not to show my stomach on The Ruddle Show. Is that the same with you?
Yeah. Lori has a very strict moniker for me.
No nudity is allowed. So, I don't show anything except just hands and face.
I also, like, tend to wear long sleeves because it's pretty cold on the set.
I like to have a set just like an operatory.
But Lori does a great job. She has our backs. You always look great. She tells me if my bangs are parted or my hair's sticking up, and that happens a lot. So -- okay. Well, since you look good, and I look okay, then we will now do our 80th show.
SEGMENT 1: Annual AAE Meeting
All right. Today we wanted to shoot a special segment on the upcoming AAE meeting, which runs May 3 through 6 in Chicago. So, we planned to go over the educational tracks and highlight some topics that we found interesting, and then we also have some videos to show you from six speakers, talking about what they plan to present. So, we'll show you those as well. So, here's the educational tracks. I have them behind me.
It seems like that there is usually some core segments that are the same every year. And then, there's usually a couple of new segments that are rotated in. And the first one is a new one, and it sounds exciting. It's called "The Future of Endodontic Practice." So, what would a clinician maybe expect to find under this track?
Pretty much everything from A to Z. It's a big track. I think the AAE states this in their marketing piece, but they say it is the latest in science and innovation and, of course, what's trending. Specifically, it's a little laundry list, so I'll just read it to you. There is going to be intrigue, with artificial intelligence, and virtual visits and augmented reality. We've talked about that quite a bit here. So, hopefully, that'll spawn interest. There's going to be interest, of course, in the future of endodontic education, DSOs, retirement, transitions.
There's gonna be regenerative endodontics. That's gonna be thrilling for a lot of people because there are some strides forward. And finally, you know, the same old things keep cycling. We're gonna talk about -- I don't like the word -- "instrumentation" and there's going to be emphasis on irrigation and filling and all this, of course, in minimally prepared canals. I don't particularly like the word "instrumentation" because instrumented canals are neither cleaned nor shaped.
Well, you would definitely expect to find stuff about AI in this track. And I could even see AI spilling over into the "Practice Management" track, as more practices start to incorporate AI in a administrative way.
And actually, I'll just make a prediction. I think that maybe ten years down the road AI will be interwoven into all aspects of endodontics, clinically and administratively. So, that's just my prediction. You guys can let me know in ten years if I was right or not.
Okay. So, the next track is "Interdisciplinary Collaboration" track. And sorry, we don't have any speakers to -- any videos from any speakers in the -- in the "Future of Endodontic Practice" track, but I think there's a lot of interesting topics there. So, the "Interdisciplinary Collaboration" track.
This is a really interesting track in that it's what professionals should be doing all the time, and that is interacting with each other outside necessarily your discipline. I mean, it's fine to get a second opinion from another endodontist. But it's also fine to think about calling up a physician. There's a lot of -- gonna be endo medicine type things. There's gonna be endo pediatric dentistry type things. We also think of the adult tooth, but there's gonna be a little focus on those kids.
And then, there's gonna be a whole bunch of things. We're gonna have pain, and they're
-- they're gonna talk about pain. That's good. I think it's Hargreaves again. Great guy. And then, we're gonna see a little emphasis on things like big, bad lesions or something. Big, bad lesions in bad places or -- it's very --
-- it's very threatening to me. So, I didn't read it completely, but I thought I'm intrigued.
Okay. Well, we have two videos clips to show you from speakers in this track. The first is by Dr. Vanessa Chrepa, and her presentation is called "Dual Concerns: Endo and Periodontic Perspectives of Case Management." So, let's see that video.
[On video] Hi, everyone. This is Dr. Vanessa Chrepa. I'm here at UT Health San Antonio. I'm an Associate Professor of Endodontics. And this year at AAE, my dear colleague, Dr. Georgios Kotsakis at Periodontics, and myself are going to be talking about endodontic and periodontic perspectives of case management. It's a great topic that I really like because I face challenges with teeth that have endodontic and periodontic involvement. So, I'm happy to hear anything about your concerns at this class about how we manage these cases from an endodontic and periodontic perspective.
So, what you can expect is that we're going to define endodontic and periodontic relationships. We're going to discuss the factors that may affect the prognosis of such cases and how to manage cases in our private practice. So, we'll see you all on Friday, May 5th, at 1:15 p.m. in Chicago this year.
Okay. There you saw it. I'm pretty excited about that lecture she's gonna give because, actually, in just a few minutes, I'm gonna be lecturing about the same thing. And I think there needs to be -- you know, we have this great big emphasis on minimally invasive endodontics. How about, you know, maximizing remaining dentin? How about maximizing remaining roots?
Okay. Great. And then, we also have a clip from Dr. Alan Gluskin to show you, and his presentation is "Iatrogenic Mishaps: Clinical and Legal Considerations." So, let's see that.
[On video] Hi, there. I'm Alan Gluskin, a Past President of the AAE, and Professor of Endodontics at the University of the Pacific School of Dentistry in San Francisco. I will be presenting at AAE '23 with Dr. James Swift, Professor of the Division of Oral and Maxillofacial Surgery at the University of Minnesota. I hope you can join us at AAE '23 in Chicago on Thursday, May 4th, for "Iatrogenic Mishaps: Clinical and Legal Considerations."
Jim and I will discuss neurologic injury and other significant injuries as a result of endodontic mishaps. The presentation will review the current data for prognosis of injuries and how to determine treatment and intervention strategies in endodontic mishaps. A discussion of practitioner incompetence and its relation to mishaps will also take place. The surgical discussion will examine orofacial neuroanatomy, the spectrum of trigeminal nerve injuries, neuropathic pain sequelae, and especially surgical and nonsurgical as well as rehabilitative interventions.
So, I hope you can see this 90-minute presentation will be full and engaging. AAE '23 will allow you to earn up to 28 1/2 CE hours with 7 educational tracks in over 130 sessions. Chicago is a world-class destination, and I hope we can see you there. Thank you.
Well, I've known Al Gluskin for -- I hate to say it, but since the early '70s. So, he was a young dentist on the staff at University of the Pacific, and I was a student. So, he was one year ahead of me, and we were both looking forward to getting applications back of acceptance from postgraduate school. How about that?
So, anyway, I've known Al a long time, and we actually wrote a chapter together in the Journal of the American Dental Association entitled -- well, it was just about thermal injuries. That was with Ed Zinman. Ed Zinman is a dentist, legal guy, attorney, officially. So, Gluskin and Zinman have done a lot of good things together about endodontics and iatrogenic events and how to stay out of trouble and stuff like that.
Okay. Yeah. One thing I'm always wondering about is what is the difference between something that's malpractice and then, like an honest mistake that maybe you tried your best, but circumstances were just beyond your control, and things went bad. So, maybe that is a future "Knowing the Difference" segment, and maybe we can even actually ask Dr. Gluskin to weigh in on that. Because, you know, I am always wondering about that, and I've asked you, I know -- you know I've asked you about that quite a lot.
And then, another thing that I thought was kind of a little bit funny, but how he referred to something going wrong as a "mishap." That was new to me. Like, it seems like a mishap seems so mild and not very serious. It definitely doesn't sound as serious as, like, an endodontic error. So, it kinda reminds me a little bit of how they talk about a broken instrument as separated or disarticulated. So, yeah. I like the euphemisms. All right. So, wait. Let's go to the next track now, "New Voices."
The "New Voices" track is going to feature up-and-coming speakers of the future. So, it's pretty exiting to see who might be out there and be a diamond in the rough. And maybe it's -- they're go from AAA ball to, like, a show. So, I don't know. But anyway, we have a lot of things that new kids want to know. They want to know like how you take the Boards. There's classes on that.
These kids are gonna hear from speakers who are saying how to get started and transition from grad school to your first practice, whether you're in a DSO, a private practice, or a group practice. Of course, they wanna know about how to develop relationships [laughs]. Not such a bad thing to want to know. And then, of course, I guess one of the people that we're gonna see real soon, and I'm really to see the new talent coming in clinical abilities. So, I think we have maybe some really interesting people that can get the job done with their hands and mind.
Yes, we do have a video to show you from Dr. Brent Hiebert. And we've actually known him for a short time now, because he participated in the Ruddle with the Residents program that we -- that we did. And he actually graduated from Loma Linda University. So, let's see what --
-- Brent Hiebert has to say.
[On video] Good morning or afternoon or evening, depending on where you're watching from. First like to thank Cliff, Phyllis, and The Ruddle Show crew for having me on. My name is Brent Hiebert, and I'm a Diplomate of the American Board of Endodontics. I own a private practice specialized in endodontic care in McMinville, Oregon, and I've been practicing in dentistry for a little over 13 years. I graduated from Loma Linda. That's endodontics, where I got my Certificate and Master's back in 2017.
And I'll be lecturing this year at the American Association of Endodontics meeting in Chicago. And the title of my lecture, "Top Gun Endodontics." So, what does that mean? Well, if you come to my lecture you're gonna get a top gun endodontic experience, meaning you're gonna see really cool cases, really interesting cases. They're all gonna have videos, photos, radiographs, and it's gonna be a really entertaining lecture where you, the audience, will be able to hopefully be entertained, but also learn how to manage more difficult cases. And you'll see basically firsthand how I do that.
So, what I would recommend is buckle up, hold your shoulder straps on, and get ready to go. And I hope to see you guys in Chicago. Thanks again and have a good day.
Okay. So, it's been a lot of years since Brent might've floated through and was with the Ruddle with the Residents, but I have been following him on the Discussion Forum, the AAE Discussion Forum. And I will have to say, I'm very excited about his future. I think he's gonna make a major difference because he likes to teach, he documents, and he does some superb work. He likes those truss accesses. I'm gonna have to call him up. You know, Brent, you did give me your text. I can text now. You gave me your cell phone! So, that was a big hurdle in our relationship! So, that's great. I'm gonna text you about that. But anyway, he's gonna be good. He's gonna be good.
I did note --
Standing room only.
-- I did notice -- I wonder if his dog will be there, because I noticed he is a dog lover. And I don't know too much about his endo, but I could tell from his shirt that he's the best dog dad. So [laughs] --
Well, you know Brent has no problems with collections, because the dog is well trained in practice management, and nobody ever leaves his office without the dog making sure the account is reduced to zero.
[laughs] Okay. Well, next track is "Non-Surgical Root Canal Therapy."
Wow. This is a really good track because I think it's something that's missing a lot as dentistry's evolved. When I give my lecture here in a few minutes, you're gonna see what we were doing in the profession '50s, '60s, '70s, and '80s. There was a lot of interdisciplinary. So, this track's gonna bring us right back to communication and working together and seeing the case through each other's eyes. And I think specifically -- well, it's got everything. I -- as I stand here and look, there's again the word "instrumentation," not shaping. But there'll be classes on how to move files, I guess, and instrument appropriately for irrigation.
So, there's a lot of things happening, as you know, in 3D movement of fluids. Filling root canal systems, I hope they're gonna talk about systems. Maybe they're just gonna fill canals, but probably systems. And then, there's cutting-edge technology, managing stuff. There's broken instruments. We're gonna hear about micro tissue engineering, trauma, vital pulp therapy, and wow -- resorptions. And I was reading an interesting thing about resorptions and why are we seeing so many resorptions and then -- that's another topic. It's not my time. It's the AAE's time. But I wanna know why there's so many resorptions.
Well, that's maybe a future segment.
Maybe we have to go to the lecture.
All right. Well, in this track [laughs], we have a video by -- to show you by Dr. Bettina Basrani. And she's gonna be facilitating a debate. So, let's hear what she has to say.
[By video] Hello, everybody, and thank you, Dr. Ruddle, for giving me this opportunity to share with your audience what's going to happen within the annual meeting at the AAE '23 this year in Chicago. My name is Bettina Basrani, and I am one of the track organizers for the non-surgical root canal treatment. And I'm very excited to also facilitate one of the great sessions. The session will be kind of debate, point-counterpoint, between Dr. Domenico Ricucci and Dr. Stephen Buchanan on the importance of patency file and the long-term outcome. So, I hope that you can join us for this great seminar and point-counterpoint, and I'm very, very excited to be part of this event. Hope to see you soon. Bye-bye.
Well, this seems kind of like an intriguing topic. I am wondering who is pro-patency and who doesn't think patency is so necessary. I hear you so often emphasize the importance of patency. So, I'm wondering if this is really meant to be a helpful debate or if it's more just like a exercise in cleverness? I don't know. Do you -- do you think that there exists a reality where you would go to this lecture and -- or this debate and listen to it and come away thinking, you know, maybe patency isn't so necessary? [laughs]
At this stage of endodontic development, it is a completely silly notion to have any debates whatsoever on patency. Anatomically speaking, all the foramina are open! Did you hear the word? "Open." They're not blocked, and they're not occluded, and neither are they relocated. So, at this age of development, we only use a patency file to maintain what was already present and to verify that we're patent. So, it would be fun to go see the two people debate because it would probably be like watching Schilder and Frank Wine, back in the day, filling the room up, and they would get on their gloves and go 12 rounds.
Okay. Well, then we have the "Practice Management" track.
And I -- I like when you said; we're just moving quickly through.
Yeah. Moving right along.
Okay. So, in the "Practice Management" track, there's topics like teambuilding, hiring and firing, communication and business dynamics, all stuff that we've talked about on our show. We do not have any videos to show you from any speakers in this track. So, we're gonna move on to the last one, "Surgical Root Canal Therapy."
Fascinating track from my standpoint. I've been involved in surgery during the Renaissance, back in the days. So, anyway, when I saw the categories, it was fascinating that it's not just apicoectomy, you know, retrograde type procedures. But there was -- there's gonna be a complete look at -- there we go again -- root amputation! My God, everything old is new again. And then, there's gonna be guided tissue stuff, and there's gonna be piezoelectric access that's guided.
I actually wanted to ask Steven Niemczyk, Bertrand Khayat, Enrique Merino and Jean-Yves Cochet, they're all dear friends of mine from all over the world, but there was only one, and only one that was close, and that was close to my heart, and that was Mahmoud Torabinejad. So, I thought Mahmoud might be one of the elder statesmen in the profession, and we should hear from him.
All right. Well, let's see his video.
[On video] My name is Mahmoud Torabinejad, currently living in Laguna Niguel, California, and I'm associated with several universities at this time. The topic of our lecture at the AAE in Chicago is anatomic zones in surgical endodontics. At this lecture we will show a number of videos and explain why we need to know the relationship between the maxillary and mandibular teeth to the surrounding vital structures during surgical endodontics, explain how to prevent mishaps and serious complications during surgical endodontics, and finally, we will provide the information regarding the comparisons of actual dissections with those of CT scans. Thank you very much.
Okay. Well, I do think this lecture would contain a lot of useful information. Even if you're not a general dentist that's doing surgeries, just knowing what the anatomical zones of concern are would be beneficial, like when you're referring, like how you communicate to the patient what's possible. So, I do think that that is probably some useful information that everybody should know, what are the anatomical zones of concern.
All right. Well, then, we have one more presentation we want to highlight. And it's not included in one of the main educational tracks. It's actually a "To the Point" lecture. So, what is this exactly?
This is pretty exciting because it's new technology. So, companies get to, you know, present the launch of their new product. And I guess maybe at the AAE this year we're gonna see Surround Medical Systems will launch their PORTRAY X-ray unit, and that's gonna be focusing on guess what? Small, intraoral tomosynthesis -- tomosynthesis -- tomosynthesis. Okay. Do you remember that? We had a show, and I think it was just last week, that had --
Couple weeks ago, I think.
-- couple weeks ago we had Professor Tindal, and he was giving us all the physics and, you know, all the things we need to know as dentists about this technology, the slices and how to access things. So, now we're gonna have David Landwehr talk about that. And David Landwehr's gonna be on this show I hope next season. David, if you're listening, I can oil off your -- your lecture and get it polished up and get it ready. But it'll probably be something you've never done before. So, that's it.
All right. Well, let's see what Dr. David Landwehr has to say.
[On video] Hey, everyone. I'm David Landwehr, a private practice endodontist in Madison, Wisconsin. Today I'm gonna give you a one-minute rundown on the To the Point lecture I'm going to be giving at the AAE meeting in Chicago in May. The talk is titled "Is Periapical Imaging Passe? Stationary Intraoral Tomosynthesis Applications in an Endodontic Practice."
The title implies that I may not be taking periapical images in my clinical practice, and immediately then one might assume I'm only taking a CBCT for every case as my sole imaging modality. However, this isn't the case. The second part of the title states, I'm gonna be discussing stationary intraoral tomosynthesis. SIOT uses a fixed array of x-ray sources to generate a series of images, which can then be manipulated with computer software to construct a three-dimensional periapical image.
Specifically, seven images are generated from different angles and laid over each other. Stationary intraoral tomosynthesis has a comparable radiation dose to current intraoral radiography. And I'm gonna discuss several clinical applications where stationary intraoral tomosynthesis performs better than traditional intraoral imaging. This presentation's gonna explore the technology behind SIOT and its potential applications while addressing current 2D intraoral and CBCT limitations.
I wanna thank Dr. Ruddle for the opportunity to promote my talk. I'm really excited to see how this technology is going to evolve and to share with you how I'm gonna incorporate stationary intraoral tomosynthesis into my clinical practice on my never-ending pursuit of clinical excellence. I hope everyone's gonna join me in Chicago.
Okay. So, this is kinda neat because on our show a couple of weeks ago we got the perspective of an academic endodontist, Dr. Tindal, talking about the 3D tomosynthesis.
And now, if you go watch Dr. Landwehr, you'll get the perspective of a everyday practicing endodontist. So, that seems like it could be beneficial.
All right. Well, that's all the time we have for today. If you wanna know more about the AAE meeting, then go to it. [laughs]
Yeah. Go online, check it out yourself, and if you've got a little window of opportunity, head on out to the city of broad shoulders, Chicago.
Yeah. I think Dr. Gluskin said it best, like he reminded us that Chicago's a world-class destination and that there's lots of CE available. So, definitely go check it out.
SEGMENT 2: Endo/Perio Considerations – Root Amps, Hemisections & Implants
Everything old is new again. You remember that saying, and it's nothing more appropriate with that saying than right now, today, with what I'm gonna do next. You know, from about 1950 -- I just made that up -- it could've been the late '40s -- but for the next four decades, the '50s, the '60s, the '70s, and the '80s, we did a lot of endo/perio. And there was a big emphasis on preserving teeth. And I mean even segments of teeth. So, that was the era, and there was a lot of interdisciplinary treatment. There was the restorative dentist, the quarterback, and then there was an extension of that, and that was the periodontist and oftentimes the endodontist.
So, together, through interdisciplinary treatment, we were able to save and retain teeth. And just like we put tremendous emphasis -- listen carefully -- tie this together -- with minimally invasive endodontics, back then they were practicing minimally invasive dentistry. In other words, minimally invasive endodontics is preserving, maximizing remaining dentin. Endo/perio is maximizing the retention of critically essential roots. So, that's a little bit to get started. And of course, it's nice to remember that we have implants.
And so, why'd I stop in the '80s? Because Branemark, in 1965, in Sweden, put his first four fixtures in, and there was a 40-year recall. But back in '65, him being a physician, he recognized that pure titanium could osseo integrate, a word he coined, with bone. And so, you got a union. And he was very, very excited about that, and that led to the implant era. In fact, if you go forward, in 1970 roughly, the country of Sweden recognized dental implants officially as an extension of preserving the dentition. It took quite a few more years to get over here, but in the early '80s, the Branemark implant system was the first recognized implant system in the United States, and then everything followed.
I won't show you the curves and go over all the numbers, but when implants came in, it began to tamp down a little bit the hemisections and the root amputations, because that was considered kinda going out on the limb. But for a lot of patients, they got decades out of those combined treatments. So, implants kinda slowed down, tapped the brakes, started to slow everything down on the implant hemisections. But then, after about 20 years or 30 years of implants, it wasn't quite the panacea we all thought. Yes, it was a great procedure, here to stay, will continue to grow in the future immediately ahead.
However, we started seeing things like implantitis, and we've talked about that on the show, and we've talked about how you might have to use an ER, CR, YSSG laser to go in there and clean out those infrabony pockets. And what do you do when disease recedes down and you get bacteria on the first thread? Doomsday follows shortly thereafter. So, we wanna prevent the recession. But the point is with the implants, it began to kind of bring us back. The pendulum began to swing back to what if we could do more endo if it was appropriate, if the teeth were restorable. So, that's my talk today.
That's the setup, and we're gonna talk about all the endo/perio in the era of minimally invasive dentistry and implants. So, you see a patient. They come in, and you see what appears to be pretty good endodontics. You might look right here. I wanna show you something you just never see. But anyway, this tooth looks pretty good. And this is two different angles. This is the horizontal mesial angle, straight-on angle. The lateral bone looks pretty good. You might say, well, I might see a little something in here. But I don't think anybody would stop their day to say, gee, we'd better follow up on that, unless the patient had symptomology.
So, when they did, if you brought them back, and you took a CBCT, you can begin to see the etiology is a great big apex to crown, lateral root lesion, the kiss of death, and it tends to suggest a fractured root. And in fact that's exactly what it was. So, in this case, endodontics has done everything it is capable of doing, and in spite of all of our best efforts, the tooth was lost. I wanted you to see this, and I wanted you to see this. You almost never get to see that. Look at how tight that bone is around the end of that terminal portal of exit. That was great endodontics. Thank you, Fulton E.! Thank you, Fulton. All right.
So, the teeth are removed. The periodontist in this case came in, he placed the fixture. And you know they're maestros of the soft tissue, so they can swing flaps and do all kinds of neat things. This was guided implant placement. So, X-NAV was the technology. X, Y, Z in the depth, and there it is. So, it's restored. You can see the bone level is good. I was talking about what do we do when the recession occurs, and we get to the first thread! And when we get to the first thread, that is doomsday for a lot of implants. So, anyway, that's what implants can do, and I will stop speaking about implants other than to recognize, so you know I know, we're gonna do them.
We're gonna refer patients to get those fixtures placed in, and then we'll get them restored, and that will be very, very good service for the patient. Let's come back, though, and revisit what else can we do. And if you come back and start to revisit, I've been involved in hundreds and hundreds, if not a few thousand of these kinds of patients, where you can see an abutment. You could use that, you could use this butt. You could put a three and a bridge in, but as heavily restored as these teeth are, you're thinking about the pulp. Of course, you are. And then if you think, well, what if we could keep some segments and do some minimally invasive dentistry where we can shorten the three and a bridge?
Well, you might say, plop an implant in. You know what? I lay all this out for my patients, the cost, the time, the risk, the benefit. You project the ultimate prognosis. And with these things in mind, patients make the call. Come on! You don't make the call. You're supposed to be Grand Central Station, and you're directing traffic. And if you're honest, and you know your material, you can direct them usually where patients will co-develop with you and co-design and co-treatment plan, and they'll want to do something very good. So, we did a lot of those. And I'm gonna show you these cases later. And then, of course, there were a lot of root amps.
So, I'm gonna -- in general -- this isn't true, but in general, hemisections are mandibular entities. Root amputations are typically maxillary entities. You can imagine that there was a furcation, and the root went up in here like this. A lot of you come in here, and you do that. That leaves a big, uncleanable shelf. So, you have to know what the periodontist knows. You have to know how the periodontists are thinking. But notice how this is ramped. Notice how that's concave, free flowing for cleansing. Remember, when you're done, the patient has to be able to maintain this over potentially years and years of their life.
So, don't forget to not only ramp down like that, but then you gotta ramp it back. Everything is, you know, contoured, smooth and flowing. You can take an explorer, you can drag it any way you want, and it's gonna slide right along. Now it can be cleaned. So, that's your indication that you know what you're doing. So, we do a lot of root amps, but we save the integrity of the arch of the dentition. I want to revisit this endo/perio because it's something that has been kind of left out of the treatment bag. And it used to be in there in the '50s, '60s, '70s, and '80s, like I said. Then it went away with the implants, but now it's not either, or. It should be and, both. Okay? Either, or, and both.
Let's get going. So, here's the -- I'm gonna show you four cases. And this is a bridge abutment, and you can see that it's had a lot of cleaning. Those gracie's slide over those roots. You know, you got that perio department and those hygiene -- they're there working, and they're scaling daily. They're curettaging. And they can start cupping these roots out, they can start making defects in the roots, and all of a sudden, there's a pulpitis. So, what are you gonna do with a pulpitis? Well, sure, you can take out the pulp, and that's gonna allow the patient to clean better.
But you have through-and-through furcations. You can come in from the distal and snake a shepherd's hook around and come out the buccal furca. You can come in the mesial furca, come out the buccal furca. It's a fun game in there! It's like a maze, and it can't be cleaned. But if you did try to do shaping -- if you did try to do shaping, you could see the canal right here going up like that. By the time you develop a little shape in here, you're gonna probably blow out the root and perforate. So, I'm sure the producer's yelling in my ear, I don't have my plug in. But she's saying, "The cuff of your sleeve. Please keep it off the screen! How many times I have to tell you?"
So, we take out -- we're gonna take out the buccal roots. They're hopeless. You might say, what about an implant. Well, yeah. You could do an implant, and you could also save the palatal root. So, why don't we get in there and get both systems, how about that, one of those maxillary molars with two systems and the palatal root. And it's a big root. Can see sorta the PDL way out here, and you can see the PDL here. It's a big, broad root. Got a bifidity. So, we got one canal that exits towards the mesial, and here it is many, many years later. So, the periodontist resected the buccal roots.
The prosthodontist comes in and keeps the occlusal table narrow, buccal to lingual, so the loads are right up over that root. And look at the density of the bone that that root's sitting in! And it's a big, bulky root. So, with case selection, careful analysis, CBCTs, multiple views, interdisciplinary treatment, you can map out these treatment plans, and you can give patients long-term results. Now, some of you are laughing, but I put this one in for laughs because I know nobody would do this except for Ruddle. But actually, some of my friends and I were doing a lot of these things, again, back in the '70s and the '80s.
Implants weren't -- you know, they weren't so viable, and even when they were, we had a lot of lost implantations and we had loose fixtures, and people were losing their occlusion. So, it kind of brought us back to saving roots. This has had the DB and the palatal root removed, and you're looking at the lone ranger. It's the MB root. Now, we know the MB root has a cross-section that would look about like this. So, it's a broad root, buccal to lingual. When we have concavities that's good, because we have more retention. Lock that thing in there with bone.
And so, we begin the journey. So, I cleaned the MB 1 and 2. I isolated with an ivory 9 clamp. That's an anterior. The dam goes right over it. Tooth's quite mobile. So, Ruddle put in some ligatures, sling those teeth together. But look it. You got a bicuspid. You got another bicuspid. So, you got one, you got two, and we're gonna get another bicuspid. So, we got -- we pick up the molar, okay? So, you got molars down below with molars up above occluding. And patients in first-molar occlusion are happy patients. So, you can see that if you think a little bit different, a lot of young dentists today never really lived back in the '60s or -- well, they didn't practice, for sure, in the '70s, the '80s, and the '90s, because that's still -- you know, we've been 23 years in this millennium.
So, I guess you'd have to say, you know, a lot of people just never really saw this. They might've [laughs] pulled out a few old textbooks and said, wow, look at what they were doing back then. Well, look at what we're doing now, and look at it restored, and look at the time go by, and the patient. These aren't for all patients. Hey, listen. There's a lot of patients you'd never even think about this, but if you have the right patient and you have the right interdisciplinary team, you have the right technology, you have training, and you have some experience, you can keep people in teeth for a lot of their life -- a lot of their life.
So, pretty proud of these cases. I've done hundreds and hundreds, like we said, probably a few thousand, and I did it with the periodontist, and we had great restorative dentists here in Santa Barbara. They weren't all prosthodontists. Most of them were just well-trained GPs. So, let's look at two downstairs. So, we looked at root amps, and the main thing to leave on root amps is, when there are selective defects around selective roots, maybe rather than giving up on the whole tooth, maybe you can maximize critically remaining root segments, and maybe that is the natural implant.
And when that fails, can't we still always do the implant? And if we grow bone back around our endodontic procedures, we're actually doing a regenerative procedure that will -- it'll present a better -- a better site for an implant, okay? You never maybe thought like that. All right. So, this happens in the real world. Just think of a dentist out there somewhere in the world, and they're seeing a patient that's in a lot of pain. They have frank apical pathology. Those are lesions of endodontic origin. There was a bridge on here, and they came in and they had to take the bridge off. And then, he's drilling into the tooth to find canals. He's gotta get this patient out of pain. He's gotta find the canals. He needs the abutment in the most funereal sense!
So, then, there is a perforation. Isn't that too bad? This dentist came with tears in his eyes and said, “Can you help me”? Well, geez, I'm looking at that distal root, the remaining root, if that's the one we're gonna say is viable, and I'm thinking it's -- well, I get the endodontics, so I can tell you it's about -- it's about 27 millimeters of fun -- 27 millimeters of pleasure! So, it's pretty long, but it's kinda narrow. So, I think what we had to do is just get on the same page. I'm gonna just kinda ramp this bone. I'm gonna do a hemisection. I'm gonna take out the root. I don't even know if my daughters know I do this kinda stuff. They're probably thinking, geez, he's completely -- he must be on medications today.
So, we did that. And if you look at this just after we did it, that's the tooth, the lone ranger. Fortunately, it's necrotic, so pulp's not gonna be sensitive to hot or cold, sweets, sours, things like that, sugars. So, that's immediately after the extraction and the hemisection. And now we have this long root to deal with. There's a little bit of curvature if you look down there apically and begin to plan. Treatment plan for no surprises. Think, visualize, plan, execute. And again, everybody has to do their job. I was real excited about the endodontics. That was before the EndoActivator! How about that?
You know, when I hear about instrumenting canals, I cringe because I always remember Schilder said, '”Instrumented canals are neither clean nor shaped.” So, when I was a little earlier talking about all those presentations in the AAE, they were gonna talk about instrumentation, okay. We use instruments, but we prepare canals. So, you can have a minimally invasive shape, but we still should be talking about shaping, because shaping facilitates the cleaning. And it's shaping that allows a graded series of pluggers to work unrestricted by dentinal walls and move thermal softened gutta percha into the lateral anatomy. And you get loops in multiple apical portals of exit.
And you know what? With an upper maxillary denture, you can get away with some of this a little bit more because the occlusion is just a little bit lighter. So, that's our third case. And I'm showing you everything long-term, and even if it fails, can't we come in here and put a bunch of fixtures? So, if you're really thinking about your patients and how to best serve them instead of how to best serve your financials, by doing implants, because they're so quick, and they're so productive, and my God, yeah, we're really making a lot of money on that production day, why don't you do the right thing for your patients? It'll come back in spades!
All right. Next case, last case. All right. Another molar, and you see patients all the time that show up, and they'll have a through-and-through furcation. You can take a perio probe and pass it right through on the buccal, and it'll exit on the lingual. You can begin to see the bone is ramping down already. You can kinda map it. The tooth is testing vital, so you could've argued, do the root canal, because my goodness, you might have a furcal canal. Geez! It could've even come off the floor! Maybe you get a couple of them.
I've shown you cases. You've seen that. So, you know it's possible. But with careful observation and talking to the team, the team wanted to do either an implant -- just take out the whole tooth -- or the team also thought, what if we just went in here and eliminated the infrabony pocket, the furcation problem. And notice the furcal floor. I wanna talk about the -- oh, I'm so excited to talk about the furcal floor, the furcal floor! Yeah. The floor of the tooth is just about where this bone is. If you have a furcal floor that's down like this, and your bone level interproximal is high, can you imagine?
You might section the tooth, but if the floor is way down here, it's -- again, there's margin issues, there's where is the bone gonna end up issues, there's the apically repositioned tissue factors. Those are all factors. So, this has a high furcal floor relative to the surrounding crest. So, the endodontics is not so difficult. Open it up, isolate the whole tooth, take the crown off first, of course, make your access. We don't worry too much over here. There is some calcification, but I see them. I see those guys! But a nice smooth flowing shape, a little bifidity apically.
If you're gonna do all this, I guess I better mention your endodontics needs to be on the money. If you're gonna have bridgework and prosthetic guys involved and ladies, if you're gonna have these men and women periodontists that are doing a lot of really sophisticated stuff, if everybody's gonna climb aboard and get on the bus, and we're motoring right down there to success, success is not gonna be so attainable if we miss a canal, if we're not really good on our endodontics. So, everybody needs to function at a high level. But that's the fun part of it, isn't it? That's what makes it fun.
Now, Ruddle did this procedure. So, you can take a perio probe, like I said, and pass it through and through. You notice I've got my endodontics done. I have a little amalgam. You can see these adjacent teeth are heavily restored. We talked about this one on the slide one if you can recall. So, now I have my buccal and lingual flaps back. So, I've got this thing a little exposed. Trick! Trick! When you're making your section, don't make it perfect. When you make your resection, cheat it at the expense of the tooth that's coming out. And once you get this root out and you get every -- you can begin to use your surgical ink, tape, or diamond, and you can just be bringing this back and bringing this back so this comes right out of the bone and boom! Right up like that.
So, that's what we're gonna do. So, the section is at the expense of the root that will be lost. We can get in here and luxate it, extract that root. Now! I'm not gonna be telling you all about perio today, not in 20 minutes. You're gonna have to wait for a podcast where we can get into this for like an hour, hour and a half. Geez, I have a whole new curriculum coming you don't even know about. I haven't even announced it yet! But I noticed the people out there that need the help are the people that need successive courses, one after another, each course building on a previous course, and we're gonna do that as well as the podcasts, plus the shows!
Look it! We're ramping the bone like this, just like it is biologically. We're ramping the bone. But it's not only ramping it mesial to distal. We have to ramp it buccal to lingual. We have to contour it so there's an actual crest -- a crest of bone. The socket site, you know, you guys love to put stuff in there. You put the whole thing in there. You put -- you got the shopping cart, you -- freeze-dried bone. I mean, you're putting everything. I don't. Okay? Just left it like that, put the flaps back, reposition, and suture.
And here we are at about 30 days. We have a great zone of attachment. We have a muco-gingival junction. You got your lining mucosa, and you got your attached gingiva, and oh, my God, you're loving this. It's just like Dentistry 101. And you now can have the restorative dentist take over. And here's what we ended up with. So, here's the brand-new bridge in. Here's our abutment. We have a little tiny three and a bridge. See the pontic? See how it's beveled in there like that, free cleansing, everything's free cleansing. Clean up all those trashy fillings, those leaky -- that micro leaky stuff, and put a cover on that tooth so we don't have to worry about a longitudinal fracture.
Heavily restored teeth in pretty big occlusions oftentimes can contribute to micro cracks, and those can propagate, and they can come back and be a problem. So, coverage was deemed to be appropriate. And I'll end it with this. You have a nice post-op, you can see the bridge is in there. That's a great service for the patient. And we'll close by saying we looked at four teeth, and we looked at endo/perio from the past. We looked at the evolution on to implants. Now we're doing endo/perio over here, and we stopped that, kinda. We just were doing endo now, and we're doing implants, and that trucked along.
And then, the pendulum on the implants started to swing. And now, there's quite a little surge -- I'm noticing with some of my friends -- what if we could preserve root segments to fulfill the prophecy that we've always longed for, and what was that? Minimally invasive dentistry and making people happy.
CLOSE: Aesop’s Fables & Endodontics
Okay. So, to close the show today we have another installment of "Aesop's Fables & Endodontics." And just to recap, Aesop was a slave and a storyteller who lived in ancient Greece. In his fables, of which there are over 725, the main characters are generally animals, and they teach a moral lesson. So, these stories were originally told orally to adults and were not put into a printed edition until over 300 years after Aesop died. And they over time began -- they were told to children, and they've been translated into many, many different languages and even different dialects.
So, how this works is I'm gonna read a fable and then my dad is gonna relate it to endodontics. [laughs] And just to let you know, because the -- our audience is international and the fables use some archaic language, I have taken the liberty to change a few words just to facilitate understanding. I'm not changing the meaning, though. Okay. The first one we chose because, for obvious reasons, it's called "The Father and His Two Daughters." So, that's like you [laughs]. Okay. So, here's this one…
A man has two daughters, the one married to a gardener and the other to a tilemaker. After a time, he went to the daughter who had married the gardener and inquired how she was and how all things went with her. She said, “All things are prospering with me, and I have only one wish, that there may be a heavy fall of rain in order that the plants may be well watered.” Not long after, he went to the daughter who had married the tilemaker and likewise, inquired of her how she fared. She replied, “I want for nothing and have only one wish, that the dry weather may continue and the sun shine hot and bright so that the bricks might be dried.” He said to her, “If your sister wishes for rain and you for dry weather, with which of the two am I to join my wishes”?
Okay. So, the moral of this one is, you can't please everybody.
[laughs] You can't please everybody. The first thing I thought about -- and this is called major league whining. So, here I go. So, you practice for a few years or a lot of years or decades, you really wanna practice at a high skill level, you get the right people around, and you train them. Then, you get the right technology around, then you slow down so you can document everything and have really wonderful material. Then you spend weekends and nights putting together lectures. Then you get on planes, you go on out, and then you land and you transfer to the hotel, and the next morning you're up, and early you transfer to the venue.
And then you give your all-day lecture, and you lecture all day long, you're answering questions in the bathrooms during the breaks. You're there until the last person leaves. And then you read the critiques the following day.
And the critiques were, “Well, I didn't learn much.” “He seemed to be promoting his file.” “Wow! -- It really wasted my time, especially the morning when he talked about rationale.” OK. So, I just realized -- and that's a small group of people, but if you're a speaker out there [laughs], that's the one you remember because it's that one, one, because I -- thousands of people loved it, the critiques are like 99 percent, but it's the ones that didn't get much out of it you're going -- then you go into soul searching, what should've I done different and what will I lecture on next time. Okay.
Right. You actually spend a lot of time trying to please then that 1 percent that didn't like you [laughs] because, let's be clear, 99 percent of your reviews are very, very high. So, it's just those few outliers that kinda get you, you know. Then you're just wondering --
Well, don't forget, you can't please everybody. It's nothing more than a dilemma, and dilemmas mean you have a difficult choice between two or more things. [laughs]
Okay. All right. We're gonna read one more, and this one is called "The Fly and the Bull." So, this is a shorter one…
A fly settled on the horn of a bull and sat there a long time. Just as he was about to fly off, he made a buzzing noise and asked the bull if he would like him to go. The bull replied, “I did not know you had come, and I shall not miss you when you go away.”
So, the moral of this one is, some men are more important in their own eyes than in the eyes of their neighbors.
Well, you know, we've all seen self-appointed gurus out there. And when the day's over, there's nothing remembered, nothing's retained, nothing's implemented the next day, and the speaker's flying home through the air. His hair's flying in the cockpit, and he thinks it's a wonderful day, but not much happened.
Probably what I would think of relating it to a patient is, okay. So, your patient is a very busy person, and they're a professional, and they're doing a lot of things. And during a routine cleaning, an x-ray picks up that they have a lesion of endodontic origin. They're totally asymptomatic. So, this isn't good news. So, they do what they're told because they're a good patient, and they go to the endodontist or wherever they go, or the general dentist, and they do the root canal. Root canal goes fine, perfect, everything's textbook.
And I want the audience to know that when the patient gets up and leaves, they will not miss you. They do not wanna come back for more fun. And there's an example where the dentist is thrilled. He did something really important. The patient's going, “Bye-bye.”
Yeah. I have to say I think it's happened to me where I've showed up late somewhere and said, “I'm here. I finally arrived.” And they're like, “Oh, I didn't know you were coming today.” [laughs]
So, yeah. I guess that's my experience.
All right. Well, that's our show for today. I hope you enjoyed it. And we will 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.
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Endo History & the MB2
1948 Endo Article & Finding the MB2
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