Knowing the Difference & Surgery Case Discernment & Lateral Repair

Ruddle and Lisette begin by each identifying their favorite person of the week. Then, do you really know the difference between a straightforward case that you can easily do and one that should be referred to a specialist? Case discernment is key. Afterward, with surgical precision, Ruddle discusses lateral repairs secondary to disease. Successful surgery never looked so attainable. The show closes with “What Phyllis Thinks.” What DOES she think about boating and will we find her on a boat this summer?

Show Content & Timecodes


00:37 - INTRO: Person of the Week
04:27 - SEGMENT 1: Knowing the Difference – To Treat or Refer
29:31 - SEGMENT 2: Surgery – Lateral Repairs
51:31 - CLOSE: What Does Phyllis Think? – Boating Excursions

Extra content referenced within show:

  • The Ruddle Show Graphic “Knowing the Difference – To Treat or Refer” (see downloadable PDF below)
  • AAE Endodontic Case Difficulty Assessment Form (see downloadable PDF below)
  • AAE Endodontic Case Difficulty Assessment Form (source): https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/
  • Dr. Terry Pannkuk Educational Website - Pure Dental Learning (PDL): www.puredentallearning.com
  • “Ruddle on Retreatment” DVD Series: www.endoruddle.com/Retreatment

  • Other ‘Ruddle Show’ episodes referenced within show:

  • The Ruddle Show S04 E02 – “Endodontic Diagnosis: Assessing Case Difficulty & Clinical Findings”
  • The Ruddle Show S05 E07 – “By Design… Culture & Surgical Flaps: Intentional Practice Culture & Effective Flap Design”

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

    See also Ruddle's complete Just-In-Time® Video Library at www.endoruddle.com/jit

    Downloadable PDFs & Related Materials

    The Ruddle Show Graphic
    "Knowing the Difference - To Treat or Refer"
    May 2023

    Featured Graphic from The Ruddle Show: Knowing the Difference - To Treat or Refer

    AAE Publication
    "Endodontic Case Difficulty Assessment Form"
    Feb 2021

    AAE Endodontic Case Difficulty Assessment form and Guidelines as published by the AAE (www.aae.org)

    Ruddle Article
    "Endodontic Standard of Care"
    Jul 2006

    As one evaluates the current position of clinical endodontics as a healing art, one is struck by the vast differences in how endodontics is understood and practiced from country to country, region to region, city to city, office to office, and from dentist to dentist within each office...

    Ruddle Article
    "Endodontic Diagnosis"
    Oct 2002

    Dentists are trained to thoroughly review medical and dental histories and perform comprehensive extraoral and intraoral examinations. Yet, in spite of these efforts to optimally serve patients, the dominant clinical reality is...

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    Disclaimer

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

    OPENER

    Phyllis

    …Is anything broken?

    Cliff

    We’re hungry – Come on, get those sandwiches up on board!

    Phyllis

    Where’s the sandwiches?

    Cliff

    Come on we’ve got a crew up here!...

    INTRO: Person of the Week

    Lisette

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

    Cliff

    How you doing this morning?

    Lisette

    I'm good. How are you?

    Cliff

    Excellent.

    Lisette

    And hopefully, all of you are doing really well, also. So, we thought we would start our show off today by identifying our favorite person of the week. And this can be basically anyone. It could be a stranger, it could be someone you know really well, it could even be like a celebrity on TV or a musician, or even like a sports person. So, it's just basically anyone who has really impacted your life in a positive way in the past week.

    So, how about you start? Who is your favorite person of the week?

    Cliff

    Please meet Tony Urquidez. Tony Urquidez, as you perfectly know, is a general contractor, and I met him in 2005 at my house. Lori and Mazy were there with Phyllis and me. We were interviewing him, but we were gonna interview three contractors, because we had a big project we were gonna do, and we wanted to see which ones we mentally bonded with and that could do the job we envisioned. I'll skip forward. Tony worked with us for decades. He's done lots of things at the office, your house, my house, Lori's house. But then, we had a big project all lined up in 2019 to start, and it was a big one, and it was gonna be a phenomenal project, and COVID hit. So, that knocked out construction, trades, supply lines. Everything was screwed up.

    And then, we were just gearing to get back about a year ago, and we'd had a big storm come through, and there was a tree that fell over at a neighbor's, and he was over there helping them. Long story short, they were using the chainsaws, and the tree limb sprung loose, and it whipped back and hit him in the head, broke his condyle, broke his symphysis, broke some ribs, broke some -- arm. So, that put him out. Though the good news is, he's my best friend because he's on the job, he's working. I can almost hear him next door. And so, I'm very excited that the projects are racing forward, including yours and Lori's.

    Lisette

    Yeah. I know that we've been talking about that for a long time, like getting started on those projects. So --

    Cliff

    It's nice to get a project going and then to complete it.

    Lisette

    Okay. Well, that's good.

    Cliff

    How about you?

    Lisette

    My -- my person of the week is --

    Cliff

    Let me see your --

    Lisette

    -- Austin Reeves, the 24-year-old guard on the Los Angeles Lakers. And Reeves was -- went undrafted in the 2021 NBA Draft. But then, he got a two-year contract with the Lakers, and he's really outperformed all expectations of him, both defensively and offensively. And yeah. The Lakers do have Anthony Davis and Lebron James, but greatness is expected of them. But for Reeves, it's like the unexpected surprise. And he was pretty much instrumental in their game -- their win on, I guess it was Sunday, against the Memphis Grizzlies. And that was game one of their playoff series. So, when the Lakers win, for me, it feels like all is well with the world.

    Cliff

    Not so bad, huh? We have a very good wing woman, and the shoot's gonna be great, because look at her! She's so excited about tonight's game.

    Lisette

    Yeah. You can see our kinda purple and gold thing going on. And I'm just like -- I mean, I just felt like this week so far has been smooth sailing for me. And the Lakers play again tonight, so hopefully, my good feeling can continue. Hopefully, they can get game two. So, yeah. Austin Reeves, you're my favorite person of the week. And I think we can both say that Tony and Austin Reeves have really put a little bit of a twinkle in our eye and a spring in our step this week. Don't you think?

    Cliff

    Yeah. And I guess I'd better say, behind Tony is Julie. So, you know, nothing would probably happen without Julie. Thank you so much for getting Tony down here.

    Lisette

    Okay. Well, we have yet another great show for you today. So, let's get going on it.

    SEGMENT 1: Knowing the Difference – To Treat or Repair

    Lisette

    Okay. So, it's time for another installment of "Knowing the Difference." And this is one of our favorite segments, by the way, and is inspired by a quote by the 18th-century French author, Madame de Stael, who said, "Wit consists in knowing the resemblance of things that differ, and the difference of things that are alike."

    Cliff

    Yeah. That's pretty powerful.

    Lisette

    So, today we wanted to approach this segment with regard to making diagnostic decisions. For example, clinicians who do occasional root canals might look at a radiograph and think, “This is a case I can surely treat,” only to discover during treatment that the seemingly simple and straightforward is actually quite complex, and they are in over their heads. So, today we wanted to talk about some questions that you can ask yourself, some considerations, to see if you are actually equipped to treat the case, or maybe you should be referring it to a specialist.

    Now, a few seasons back, we did a show on the AAE -- we -- not a whole show. We did a segment on the AAE Assessment Form to determine case difficulty. So, how is what we're dong today different than that segment?

    Cliff

    Well, after that segment, I stopped practicing.

    Lisette

    [laughs]

    Cliff

    How about that? It was pretty difficult. [laughs]

    Lisette

    It's a pretty, like, involved assessment form.

    Cliff

    Yeah. What I'm joking about, Lisa gets it immediately. But, you know, the assessment form is well intentioned, and I'm sure several people got around a table like this and -- they may not even have been clinicians [laughs].

    Lisette

    [laughs]

    Cliff

    And they decided, these are the guidelines for referral. So, it's two pages, it's single spaced, it's quite complicated. As I said to you during one of our calls, I doubt people ever look at it, frankly. I think the people that are authorized look at it regularly, and it guides them, but I don't think the masses do.

    So, I think we have a lot simpler way to look at it. And I think it's gonna be six things that boil down to three things. But all of a sudden, you only have to remember six things, and then, we're gonna go to the board. This is really why it's getting to be our favorite spot. Resemblance and differences and things that look alike, yeah. They're all radiographs. We're gonna look at those, and we're gonna look at, just randomly, what I see and what you see.

    Lisette

    Okay. So, that -- that's -- I'm looking forward to that, and our viewers will get some pointers on how to distinguish between a simple case and a more complicated case, radiographically speaking.

    Cliff

    How Ruddle looks at that pre-op.

    Lisette

    Okay. Well, we do -- we're gonna start today by talking about some questions you could ask yourself to determine if it's a simple case or a difficult case. And we have a list. So, why don't we bring up the list?

    Cliff

    Aha!

    Lisette

    Okay. So, the first couple questions on the list are -- are fairly obvious, and they're related to the clinician. Number 1, what is your experience training, and do you have the necessary technology?

    Cliff

    It's fine to be trained really bad and then have long experience on poor training. So, experience [laughs] should be starting after you're well trained. So, well training means, you know, you understand your way around the block, you understand what a tooth looks like, you know the anatomy. Hello! Do you know the anatomy out there? Do you just get a terminus, one termini, or are you getting curves and multiple portals of exit? So, not only having the experience, but the experience should follow correct training, good training, solid training.

    And then, technology, of course, you know, like two easy ones that we always talk about are microscopes and CBCT. So, you can say, “I got them,” but can you use them? Because when I got my first microscope -- it's different now, years later, there's courses and stuff. But it's gonna take a few months, probably, to start to feel pretty proficient and like it's something you're not even thinking about. You're just grabbing your scope. When you get the CBCT images, do you know how to store them, read them, retrieve them, share them, and all that? So, yeah. You gotta have appreciation for the technologies that could help you be the best you need to be, to do modern-day endodontics.

    Lisette

    Okay. So, you ask yourself these couple questions, and you determine that you do think you are the person for the job. You have the experience and the training, and then, you have the technology in your office that you regularly utilize. So, then, the next question is who is the patient? What does this mean?

    Cliff

    Well, our patients come in all different varieties, sizes, and forms and shapes and complex emotions. So, the -- we see everybody in life, from all walks of life. So, what I mean by this, and of course, you know what I’m gonna say. But be very familiar with medical histories. They're complicated these days. People are living longer and of course, they come in with long lists of medications they're on.

    So, understand your patient and that you're comfortable treating this. They may have compromises, they may be a bleeder, they may have hypertension, could've had a heart attack three weeks ago. So, know your patient. Other things are if you get past, okay. I can deal with the medical history and the complexities there and the meds I'm gonna give --

    Lisette

    And allergies. They might also have allergies.

    Cliff

    -- allergies would be part of that medical history because you gotta know these things before you start. “I can't breathe”! Okay. I won't put the rubber dam on your nose, I'll put it on your tooth today. How about that? Oh, I told a joke, didn't I?

    Lisette

    [laughs]

    Cliff

    Okay. So, then, you know, can you get an x-ray in there? Can you -- are they gonna gag, because there's gaggers? Can they open wide for a procedure, theoretically? So, do they have temporomandibular joint problems, things like that? You're gonna isolate the tooth. And then, you know, there's the task at hand. But medically speaking -- medically speaking, there -- there's things you need to know.

    I have a little more list here. I said, open your mouth. Can you -- do they have a gag reflex? Are they gonna start gagging? Because that can make radiographs during treatment very difficult. And then, of course, people come in pain. And they can have pain and swelling. So, there's a whole range of swellings, from, like, board-hard cellulitises to push here, and it goes over here, it's fluctuant. So, anyway, those are things that I'm thinking about.

    And pretty much the first three things we said are things we probably won't have to ask -- they shouldn't have to ask themselves again. Everybody knows how you're trained. They know about your experience. And they know if they have the relevant stuff on board to do a good job. So --

    Lisette

    I mean, I guess a couple other things that can make a patient harder to deal with are maybe they have a really unpleasant disposition, and they're just always -- you feel like you're just always butting heads with everything you do and say to them.

    Cliff

    I kinda was trying to skip around that one. You're bringin' me back. I remember, I started it off by saying they come in all sizes, shapes, forms, and emotions. Yeah. You can have -- if you see a -- a disposition that's a little tricky, even if you think, “I'm pretty skilled, and I have experience,” you might just say, “I'm gonna have a lot more fun doing laminates today and doing crown bridge and restoring an implant,” and let somebody else take on the more challenging -- yeah. Good point.

    Lisette

    And then, also, like a special needs person might need a little extra care. So --

    Cliff

    Well, yeah.

    Lisette

    -- you wanna make sure that you're equipped to handle that. So -- okay. So, say you have the experience, the training, the technology, and you believe you can handle the patient. Next questions to ask yourself are what tooth is the culprit and has the tooth been treated before or are there any special circumstances?

    Cliff

    Yeah. Very simply said, where is the culprit tooth? You know, this one, versus the one back behind and under the collar, that's really hard to get to. So, which tooth is gonna make a difference. Has it had primary treatment, or are you looking at a tooth that needs retreatment? And that could even be disassembly and surgery. But as we'll see when we go to the board, I'm gonna just crown down. I mean, I'm gonna look at what's the crown look like, you know. Is it got any anomalies, extra cusps? Is it got a heavily restored tooth, multiple restorations? Is anything gonna fly off during access?

    I'm looking at the periodontal tissue, infrabony pockets. Is it an isolate perio, generalized perio? I'm looking -- is there a pulp chamber? Can I get in? Is it calcific? If I can find the chamber, then, are there canals? And which way do they go? How long are they, how wide are they, and how curved are they, or recurved? In retreatment, missed canals, blocks, ledges, you don't see them radiographically, but look for short fills. When you see short fills, anticipate maybe blocked, maybe ledged, broken instruments, curves, metal post, non-metal post, gutta percha, silver points, carious paste removals. Those are all things that you would look at if you were a clinician.

    Really, these last three things we're talking about are the things they should be able -- which tooth is it, and what is involved in getting into this tooth and retreating it or treatment?

    Lisette

    Okay. Well, the last question --

    Cliff

    I left out 12 things.

    Lisette

    -- okay [laughs]. Well, the last question, I actually really like. I think this is maybe one of the best ones. If you were the patient, would you want you to do the root canal?

    Cliff

    Really? Out of the six questions, would you let yourself do a root canal on you? Oh, my! That kinda brings back the integrity, the -- the sincerity. It gets the ego put away in the top drawer. You know. Yeah.

    Lisette

    I think Schilder told you something you wanna say.

    Cliff

    Oh, well, that's my favorite endodontic quote. "Make yourself the patient, and you'll have the answer," da, da, da [in singsong voice].

    Lisette

    Okay. So, you -- you go over the six questions, and you think I am the person for the job. And so, you start --

    Cliff

    Wow.

    Lisette

    -- [laughs] you start treatment, and you immediately run into problems. At what point do you stop, temporize the tooth, and refer?

    Cliff

    You know, Lisa, I've taught this for, like, almost 50 years. Always stop five seconds before the event happens!

    Lisette

    [laughs]

    Cliff

    That's like telling your patient that says, “I'll think it over,” tell them to call you five days before the flareup.

    Lisette

    Okay. So, yeah. Just maybe stop, and don't keep trying to drill and mutilate the tooth [laughs], I assume.

    Cliff

    Yeah. And do the ones you can do capably. I've always said, "May your reach exceed your grasp." So, we're not saying you're grounded. We're saying, do a lot of root canals, but, like, let's have a little honesty and integrity. Hey, I'm gonna close with this. This is my close. 90 percent of my practice, for the last 15 or 20 years, was retreating other people's root canals. So, when we say, “Make yourself the patient, you'll have the answer.” All those failures I was seeing and retreating, they never asked that question.

    Lisette

    Okay. Well, I mean, I guess don't be discouraged, too. Maybe you can't treat the case today, but maybe with some more training and practice, you can treat it next year. So --

    Cliff

    Absolutely! [claps hands] That's it. That's the attitude. Not today, tomorrow!

    Lisette

    [laughs] Okay. So, hopefully, you all have a better idea on how to determine if -- if it's a difficult case or an easy case that you can take on. I -- I think now is a good time to go to the board, and we could look at some pre-ops and -- and see what -- if they're simple or difficult. Maybe we'll look at some, and we'll think, “Oh, this is easy,” but then, you tell me it's not that hard [sic]. Or maybe, even alternatively, we look at one, and I -- I might think, “Wow! This is really intimidating and difficult,” but then, you tell me it's actually not that hard.

    Cliff

    Let's get to the board! This is exciting stuff! Ready?

    Lisette

    Let's go look at some cases.

    All right! So, here we are. We made it over to the board, and we're gonna look at some pre-ops of some anterior teeth, mostly because these are the teeth that a clinician might think are easier to treat. And we're going to determine if these are really actually easy cases or not. Right?

    Cliff

    Right. And we're gonna show bicuspids. And we're gonna show molars on future segments, how we look at all the teeth. But today, we're looking at anteriors.

    Lisette

    All right. And then, we went over these questions at the desk. And now, we're gonna mostly focus on 4 and 5.

    Cliff

    Oh, it's 4 and 5. Yeah. It's not that -- I mean, really, once you're out in the field and you know who you are, you know your training, you know your experience, you know if you have CBCT, you know if you have a microscope, you know all this stuff, you're really just seeing what tooth it is. And then, I'm gonna have you start on the next case, and we'll see how you handle that. This is a very big one, right here.

    Lisette

    Okay. So, let's look at the first case.

    Cliff

    Well, I guess I should erase. Well, okay. So, Lisette knows a lot about endodontics, because she's been writing' papers and working with me for probably about 20 years, now. So, a lot of it has rubbed off. But I'm gonna still ask the non-dentist what she sees, and then, I'll say what I see, and then, we'll go to the next case. And how many of these do we have to do?

    Lisette

    I think we have about four or five.

    Cliff

    And we started off with 7, but I started off with 60, because I picked 60, because, you know, I was having fun. Go ahead. What do you see?

    Lisette

    Okay. So, I'm thinking just, on first glance, that this might not be so difficult. I -- I think there's a -- probably a lesion here. Okay. A lesion here in this area. The canal looks pretty wide, and I can see through it. So, I'm thinking it might be open. And maybe there's some damage to the crown. So, that's gonna have to be replaced. But that's kinda what I'm seeing.

    Cliff

    Okay.

    Lisette

    So, I'm thinking this might be a doable case.

    Cliff

    So, Lisette is already rolling up her sleeves as general dentist out in the field of life, and she says, “I can do this one”! All right. So, what Ruddle is seeing -- I always start crown down, just how I am, so I'm gonna always focus on the crown. There's been a history of trauma. So, we all know the questions to ask the patients, and it isn't just one tooth that got the trauma. We know that the blow and the energy's absorbed into adjacent teeth and contralateral, opposing teeth. So, I see that. Yes, we have a big canal. It's so big, we're gonna have to whisper, because once we get inside, it's going to echo. So, I see a very big system.

    Up here, I think you're gonna probably expect to be greater than about a 60 file or equivalent, and I see a little bit of moth eaten, right in here. So, there might be some resorption secondary to trauma. And like she said, the midline comes together, the premaxillaries, and we get the suture. But I'm not looking at the suture. She's not looking at the -- we're looking at this. And that is what is associated. So, I'm thinking we probably have connectors. So, I'm thinking, got the training. Who am I? Do I know how to irrigate? Do I know how to three-dimensionally move those reagents? Can I clean a lateral canal? Can I use an obturation technique that can move hydraulically into that system I just cleaned?

    That's the questions you should be asking.

    Lisette

    So, would you say this is probably a case a general practitioner could take on that does some root canals sometimes?

    Cliff

    Sure.

    Lisette

    Okay.

    Cliff

    I think a lot of general dentists are gonna jump all over that. What I'm trying to be is a little bit more thoughtful. It's not that can you get in, it's not can you get to length. Come on, everybody! Think about those next steps! Can you clean a root canal system? Well, what if you haven't ever filled a lateral canal in your life? You might say, “Gee, it looks easy. I'll see if I can do it on the first time on this one.” Or you might just say, what was number 6, "Make yourself the patient, and you'll know [laughs] what to do"? So, if that's you, what would you do?

    Wanna look at another one?

    Lisette

    Let's look at the next one.

    Okay. So, right away, I'm thinking this looks a little intimidating, because I see that it's had previous treatment. It looks to me like there's a big problem here. I would think that I would be referring this one.

    Cliff

    Okay. Since I'm gonna show that in my next segment, I won't say much about it, because I'll talk about it there. But this is a complicated tooth.

    Lisette

    Okay.

    Cliff

    And it's not complicated posteriorly. It's an anterior tooth, the ones that they like to take on.

    Another one, right?

    Lisette

    Next one.

    Cliff

    What do you see?

    Lisette

    Well, I do find this -- this big area kind of intimidating. I mean, it just looks like, oh, gosh! How are you gonna fix that? But I mean, I'm looking at the teeth, and -- I mean, I --

    Cliff

    Is your job to grow bone?

    Lisette

    [laughs] No, but I'm thinking that the tooth -- that it's probably -- I guess, this tooth, because it looks like there's lesions over here.

    Cliff

    Oh, so, we might even have two teeth involved.

    Lisette

    Yeah. I'm -- I'm thinking it's probably this tooth, and I'm thinking that it -- if you treat this one well, then, maybe this bone will heal, that maybe it is doable.

    Cliff

    Do virgin teeth just become necrotic?

    Lisette

    Is there maybe decay or something? I don't --

    Cliff

    Well, you're really thinking and anticipating the right questions. We might see a little something here. That's just a little chip there. So, really, there's no -- it's trauma again, everybody. It's trauma. So, I would say to the general dentist, which one is it? Vital pulp testing! Oh, we gotta do -- we gotta do canine to canine, and we gotta use the old ice test, and you know, a pencil of ice and see if they can perceive cold in these teeth. Normal limits. This is normal limits. This is normal limits to cold. So, that means this doesn't respond to cold. This is the one. I see something right in here.

    That looks like a little punched out, to me. I won't retrace the lesion, but it's caused the roots to diverge, okay? So, there's a -- you know, a lot of divergence. And then, I rarely say to the audience, you can see lateral anatomy on films, because we only see to about 50 microns. But if you stand back, and we're a little bit close, there is something right in here. And maybe I should do it another way, right in here. So, again, it sounds basic, but if you're treating teeth, you're treating anatomy. So, what surgeon would wanna go in and do any kind of procedure on your body and not have familiarity with the anatomy? So, can you clean? Can you fill? What do you think's gonna happen? And can you get the roots to line up? We have to have later orthodontics. What are you gonna do?

    Lisette

    So, this would be an example of one that maybe is -- initially, it looks very complicated, but is maybe possible?

    Cliff

    It's probably the simplest tooth we've shown so far.

    Lisette

    Okay.

    Cliff

    We've only shown two, but you see you're gonna be able to get inside nicely. You see a big, open canal. Ruddle can read it all the way down. I can read it all the way, like you can, right to the terminus.

    Lisette

    Okay.

    Cliff

    So, I just -- the -- the thing that might be hard now is this big lesion. But when I was joking with her and say, well, you don't -- she has to grow bone. She said, I have to be -- all that bone's gotta come in. No, her job's to treat the tooth, and the body will do its job.

    Lisette

    So, maybe if you treat this tooth, but then, after you fill, you don't see any lateral -- lateral anatomy filled, right here, then --

    Cliff

    Mm-hmm.

    Lisette

    -- maybe that could be concerning.

    Cliff

    It -- it could be really concerning, but then again, we'd wait and watch, wouldn't we?

    Lisette

    Okay.

    Cliff

    So, you'd do your six-month recall, and you'd wanna make sure, you know, this is all coming in. And if it's coming in, in spite of no lateral anatomy, demonstrated on a post-op film, everything's going good.

    Lisette

    Okay.

    Cliff

    What do you think? Another one?

    Lisette

    Yeah. I think we have time.

    Cliff

    What do you see?

    Lisette

    Well --

    Cliff

    Boy, these look awfully easy. They're anterior teeth! They're maxillary anteriors. Does it ever get easier than that?

    Lisette

    -- well, are these fillings or crowns down here?

    Cliff

    Those are crowns. So, we have a porcelain fused to metal. We have an PFM here. Around the horn, we see more restorations.

    Lisette

    Okay. Well, I'm -- when I'm looking at this, I -- I actually heard a little bit of stuff that is -- gives me a little -- I know a little bit more than I'm gonna say, right now. But my initial reaction when I first saw this case is that there's a lesion up here and that this tooth looks like it could be treated. And it looks fairly simple --

    Cliff

    We see --

    Lisette

    -- but there might be a little bit of difficulty finding how it exits.

    Cliff

    Oh, good. Well, can you read the canal coming out from underneath the crown? Remember, Ruddle says, "Crown down." Follow the canal. Can you see it all the way to the end?

    Lisette

    Well, it gets -- I mean, I'm kinda wondering what happens right in this area? It looks like --

    Cliff

    Okay. Let's --

    Lisette

    -- but I -- I think I see something here and here. But then, I was actually told, well, what about over here, this area, here. So, I know that it's not as simple as I first thought. Because at first, I thought it was just this tooth, and that looked pretty simple.

    Cliff

    Well, I treated one tooth. This is Ruddle. This is the GP. The G -- it came down just like this. I -- he said, “You know, Cliff, I'm trained. I'm comfortable with apical pathology.” He said, “You know, the disease flow is out at the end of the root. If I can clean this and fill it,” he said, “I'm pretty confident I can get all this to just repair and regenerate.” And I joked with him, and I said, “Well, is this one -- is this one different than this one”? And he said, “Well, I guess not.”

    Lisette

    [laughs]

    Cliff

    And he said, 'But I'm more comfortable' -- this is -- this is draining. This has got a sulcular breakdown. You can probe. There's a little purulence coming out. So, this is a lesion of endodontic origin. This is not perio. This is necrotic. This is necrotic. You gotta do your pulp test, all the things we've talked about across the shows. We'll get all this into a -- a continuum, a curriculum, so you can just start on page one and march all the way as far as you wanna learn. So, anyway, it turns out, pretty simple teeth. You can see canals.

    I liked your comment. I liked your observation. This root is pretty regular. This root has a little bit of raggedness. So, that was the only thing I talked to the general dentist about. Just be careful. I'd be -- keep it as small as practical.

    Lisette

    Okay. Do we have another, or is this the last one?

    Cliff

    Last one.

    Lisette

    Okay. Well, this one, I initially thought when I looked at it, is that it looked, you know, simple. But then, when I started looking a little closer, I noticed that I could see all in here, and I could see in here.

    Cliff

    Big systems.

    Lisette

    But I'm not really seeing much in here, and I'm not able to really follow the canal. So, I'm thinking this might actually be resorption. I -- I don't know. Like I'm thinking there's calcification, that it might actually be hard.

    Cliff

    Okay. I don't have much to add. I think she said everything. But always look at adjacent teeth, contralateral teeth, opposing teeth. You're looking for pulp chambers. You're looking for pulp chambers. I don't really see a pulp chamber. So, she's correct. If you look at the distance from here, you're gonna have to drill probably about half the tooth. You're gonna have to drill below the bone to pick up this pocket. That's a resorption defect.

    And those of you who have quite a bit of experience know, when you put a file into the resorptive defect, does the file just come out [laughingly] on the other side, and is it oriented with the canal? So, it's like, no, no, no, no, no, no, no, and then, boom! You might find it. And then, you go and you, like, wiggle it on up and get it up to length. And then -- I treated this case. Okay? It had -- and we'll look at it another time -- but it had seven portals of exit that were filled. So, even the simple -- even the simple can have seven POEs. How about that? Seven POEs. And you for sure thought there'd be one [laughs].

    Lisette

    Yeah. The reason I knew a little bit more about this tooth is because this is very similar to a bicuspid that I had a root canal on.

    Cliff

    Oh.

    Lisette

    It had a lot of resorption in the middle. And Dr. Pannkuk had a hard time getting through the -- he got through the resorption, but finding the canal on the other side of the resorption was -- took a little bit of time.

    Cliff

    Go see Terry Pannkuk at Pure Dental Learning!

    Lisette

    [laughs]

    Cliff

    That's not periodontal ligament! Terry's my pal. He's been on the show many times.

    Well, that's good. So, we had a little lesson on Madame de Stael and the resemblance and differences and things that look alike. I think this kinda brought it in for me. And this will be fun, going to bicuspids and then molars, and we'll throw in some curve balls.

    Lisette

    Okay. Well, that's the segment, and hope you are now a little bit clearer on how to distinguish between a complicated case that a GP who does occasional -- I mean, that should be referred -- a complicated case that should be referred and a simpler case that GPs who do some root canals could probably take on.

    Cliff

    Good. And in closing, measure twice. You can only cut once.

    SEGMENT 2: Surgery – Lateral Repairs

    Cliff

    Okay. We're back at the board, and we're gonna have another session on endodontics and preserving teeth.

    I wanna talk today about lateral repairs. And to set a context, some of the shows that I'm doing on a regular basis, I would totally expect you to understand it and to be doing it. There are other shows where you'll start to do it. There'll be even other shows you'll see, and you say, “I don't do that. I might wanna learn to do that.” And then, there are other shows that you'll say, “I'll never be doing that.”

    But in the context of interdisciplinary treatment, where you're working with orthodontists, surgeons, endodontists, and all the different branches, and you're the general dentist, and you're the quarterback, I’m acting like the show's all for general dentists, but we have many endodontists listening, they would agree with this. We want you to know what we're doing, what we're capable of doing, and how we can be strategic in helping you and your patients save their tooth. And that's part of the treatment plan. So, I'm gonna show just three examples. We started off with 50 examples, literally, my multimedia team. We got it down to ten, and then I realized, you know what, three's gonna be fine.

    So, we're just gonna do three. But we'll come back and revisit, because when we speak about lateral repairs -- listen carefully -- the lateral repair could be secondary to endodontic root canal system anatomy. Maybe the colleague can't get it through the crown of a tooth in the more coronal approach. We might be doing lateral repairs because of iatrogenics, drill paths that deviate off the pathway and emanate out through the lateral side of a root. We might see posts. Today, we're gonna see some posts flying out the sides of teeth.

    And then, of course, there are pathological perforation repairs. And there'll be more that we'll talk about that, because certainly, in the era of internal resorption and external resorption, sometimes the two will meet, and we're doing combined procedures, including surgery. So, don't be depressed if you're not doing surgery. I'm gonna show you some fun stuff. And like usual, we'll just learn together.

    So, here we go. Let's pull back the curtain. Let's look.

    So, when you start to look at this, first of all, Lisa and I were having a lot of fun, you know, in what did she see. And she sees a lot of things I want you to see. And then, you'll show her some things, and you'll show me some things that we should learn to see. I see a four-unit bridge. What do you see? I see three endodontic attempts and four units. Endodontist number one went into the first bicuspid. I think you can see this. But if you look carefully, you can kinda see that, and you can kinda see that.

    So, that's kinda how our roots look. This would be the buccal root. This would be the lingual root. And the previous doc, if you went from here to the drill path, whoops! I'd better get that a little bit better. The drill path was right about the bone, wasn't it? And it started right here. Well, if you look at this distance, and if you look at this distance, you're thinking that was a pretty good effort. That's about one to one. That's just about one to one. In other words, they drilled up a long ways. When you start to see what's on the tooth, the bridge, the splint, it's fitting very, very well, patient's very happy, occlusion's great, perio's great, everything's great.

    I look at this tooth from an endodontic standpoint, and I don't see any evidence of a canal. I don't see any evidence of a canal. That doesn't mean there aren't canals. I've said in previous shows, I think my experience is, my teaching, my mentor, Alvin Arlen Krakow, you're obligated to make an occlusal access. Because what can't be seen, even with CBCTs and axial slices, oftentimes the clinician will simply find it. I also said, “If you have a hard time finding the canal, close the case, and live to fight another die.” Sometimes the next day, boom! There it is.

    I just got a note from a guy in India, and he said he closed the tooth, he came back, and he was -- it was almost embarrassingly simple. It was right there. So, that's the idea of “live to fight another day.” So, after all the considerations, risk versus benefit, weakening the tooth, we decided to go in and do surgery. But what do you have to say when you do surgery? Most of you are going, “Oh, yeah! Look at the lesion apically.” Well, if Lisa was standing here, she might say, “Is there any other lesions of endodontic origin, LEOs, that you're concerned about, Cliff”? I see something. Do you?

    Well, if you start to read films like Ruddle reads films, I see something right here. I see something right there. See if you could see it. I'll get this out of here. So, you have to tell your patients, if I'm doing surgery, what's the -- what's the odds? What's the probability of the lateral canal being able to be addressed from a surgical approach through the buccal flap? I don't know. What if it's proximal? What if it's around the corner? It's not lingual. You may never see it. You may never get there. So, the patient had to understand all this. The general dentist had to be in on the discussions.

    And weighing risk versus benefit, they said, “Well, Cliff, since it's a little tender to palpate, it might be facial, and maybe you'll be able to get to it, because it's not on a palatal.” So, a lot of words on a pre-op, but that's the kinda thinking that goes into measure twice, you can only cut once. So, the flap comes up. Granulation tissue all through here, all through here, big granulation tissue. I just -- what I've done here is I haven't removed bone. I have used a curette. I have cleaned out all the granulation tissue. And I have -- boom! There's the lingual. Boom! There's the buccal.

    Remember when we did that over here, and we did that over here. I think I can see. I'm pretty close, but we did that one, and we did that one, and there they are. That one and that one! But look at this. That's a lateral POE. This is just some tissue that hasn't been curetted off the root. There's no reason to curette these roots. You know, you want the tissue, the collagen available for reattachment on the medial side of the flap. So, that's kinda what I'm seeing. So, what are you gonna do? Well, we prep it. We prep it. So, here we are. I'm using the five-millimeter tips, the ultrasonic -- the ultrasonic five-millimeter tips. And I can go right up the long axis five millimeters. I can go right up the long axis five millimeters, and then, I'm coming through the lateral canal, and I’m going in and boom!

    Because we know the lateral canals come off the body of the pathway, the regular canal. So, I'm running right in here until I meet this hole. And when I make an "L" and I meet, the lateral repair meets the apical prep, I'm ready to fill. I'm ready to fill. So, these are things that you don't know until you get in, and they're a little tricky. So, if we keep moving the work over so we can keep seeing, there's the retrograde fills. Today, it's not important what was the material. In this era, it was EBA, ethylbenzoic acid, powder-liquid material, sets up. We know from the work of Pepe Oynick, in Mexico, Oynick & Oynick, his daughter, they wrote several articles about how Sharpey's fibers can grow into EBA several microns.

    And this was a repair material after amalgam and before MTA. Okay. So, it's all repaired. You can -- we've talked about flap designs on other shows, so we won't go into that anymore. And we'll just see how it turns out. So, there it is. Now, you can see this easier, I believe, because it's been enucleated, and all the granulation tissue's been removed. And now, what you're able to see is just this part of the prep, here. There's the five-millimeter down, the five-millimeter down, and you're hoping that'll work. Ruddle hates this! Ruddle hates that!

    That's not a system that's been addressed. It's neither been cleaned, shaped. I don't know if it's a block of dentin. Hey! If it's my case, it's a block of dentin. If it's yours, it's open, it's leaking, and there's microbes in there! I'm just kidding. Okay. So, we can have a little fun. But does it work? One thing I'm pretty proud of as a clinician practicing for, you know, well over 40 years now, recalls. You gotta have your patients back. You gotta see how these things come out. You not only learn how your patient's doing, but you learn how you're doing. We've invented many techniques, techniques that weren't in textbooks. They weren't in magazines. They weren't in journals. They weren't talked about at meetings.

    So, you need to really know how you're doing, and that's how you know how you're doing is you recall your patients that visit you. All right. So, let's see the recall. Let's slide it over. Let's look down the road. Here you are, about 20 years down the road, and you can see the drill path again, just about to the crest of bone. But you can see the bone's growing in here very, very nicely. We're probably gonna have a little bit of scarring -- little bit of scarring where the Lindemann bone cutter goes across the end of that root, bevels it, and where we have the retro prep. Okay. So, that's a little bit on case one.

    Let's pick up the speed now that you've kinda gotten into this. So, this is a lateral repair, second to our inabilities as dentists to find the canals, and in this case, to find two canals. So, surgery was to correct root canal system anatomy, lesions of endodontic origin, portals of exit. All right. Well, this is definitely a winner. I did the root canal many years earlier on -- well, this was about four or five years earlier -- on a little girl.

    And some years later, she was referred back, and the general dentist said, “Go back and see Cliff. There's something wrong with his root canal tooth.” Well, first of all, it's not my tooth! [laughs] Okay? Second of all, Ruddle didn't put a post in the tooth. Ruddle just packed it, down packed to about right there, then I back packed it to the crest of bone, I put in a cotton pellet in that area, and I put in a Cavit filling. We don't do that anymore. We don't put cotton pellets in teeth anymore. No, no! Seal them up! But that era, that's what we did.

    So, it should've been really easy to remove the temporary, remove the cotton pellet, and why would a virgin tooth that needs a root canal because of trauma -- I'm the first guy in it -- why would it need a post? Think about all this. I'm bringing up a lot more than just the case. But we don't need to put posts in teeth that we’re entering that were virgin. So, what are you gonna do with this post? Are you gonna try to take the post out? Well, first of all, I have talked a lot about retreatment. I've -- in many chapters in textbooks around the world. I've written many articles. And I have DVDs that have been assessed by the "Journal of Endodontics." All that's available. But there's a lot of things that go into it.

    When you think of a cusp tip of a canine, a canine's gonna look like this. That's the crown. Well, if I put a platform in here, and I'm trying to get a hold of a post in here and pull that thing out, I'm gonna probably break the crown. So, I don't want to take -- from a proximal view, this is a proximal view of the clinical crown -- proximal -- then, I'll probably break the crown off. It probably is gonna have to be surgery. So, I'm gonna show you two surgeries of posts going out the sides of roots. One will be a slot correction, one will be a tunnel correction. This is a slot. So, we go ahead, and we lift up the flap, curette out the granulation tissue, and you're seeing it pretty much with your naked eye through the photograph that I took that day. My assistants took it, actually.

    You can see the little serrations, the indentation. There's one. You can see another one there. And I'm too close to the board. There might be one there, and I probably see one there. So, you can see one, and then the second -- the -- we don't see that one. We don't see this one right here. Okay? So, I'm gonna not start here where I need to finish. I'm gonna get up here and get away from this delicate area where I wanna preserve bone. I wanna maximize bone. I have to get a finish line. This post is going out. I can't have a knife edge. I can't have my filling material coming down like that and have a knife edge. So, start resecting. Here we are, with the transmetal bur.

    And now that I get it that thin, I can just peel out the apical extent of the post. And now, in this -- remember we said we'd talk about a slot -- this is a big slot. Now I'm gonna lay my bur perpendicular to the post and bring it down, and I'm gonna keep bringing it down until I have a finish line. I gotta bring it down, not to where it's knife edge with the tooth, because I don't know if that's sealed. I don't know if the post is actually exiting, and it's sealed at the perforation site. Remember, we said we're trying to close off the area of a circle, and that's Pi r^2. Well, this isn't a circle. This is a big oval. It's a slot.

    So, we have a huge surface area to seal. So, I was telling you a lot about that, and here's how we managed it. You can see the gutta percha now showing up behind the post that was traveling on up to apex, length, terminus. Here's my post. Here's what I'm most happy about. This is the whole ballgame, right here! To have a curve, to have a little curve that comes right around, that I can finish my material against. I don't wanna finish against the post. So, I've said several times, I'm not sure the post is sealing anything.

    If the post was perforating, and it was really totally sealed, we put implants in the bone. So, why can't a post be in the bone? Think about it. It means it must be leaking if it's failing. So, there's the repair. So, we've tucked this thing back. We've shortened it about one, I'm pretty close again, maybe two. And you can see, we went up to about that third one, got up about right in here, about the third one. And there's the repair in, and then, there is how it looks. So, we have gutta percha. This is EBA repair material, right in here. That is what I'm really happy about, that little shoulder, where I'm finishing my EBA against dentin. All right?

    So, I've got it all tucked back in. And then, would it work? Would it work? I think it can! Why wouldn't it? Hey, if we extract the tooth, the bone works. If we can seal a tooth, endodontically speaking, root canal system anatomy present in our brain, then why wouldn't it work? So, there's enormous opportunities for us, as a profession, to save teeth. And these are all instead of implants. I'm not opposed to implants. I think implants are here to stay. They're gonna grow in the years immediately ahead. But we're gonna coexist, because of minimally invasive dentistry. It can do these things.

    The last case. Now, this case is one that is another post problem. And you're looking at this, and you're saying, “Gee, the post looks like it's going all up against” -- okay. So, what did we just say? History of surgery. So, we've got a history of surgery. Okay, great. We -- we have a -- a big post. It looks like we have a big post. We have a retrograde material. Well, what happens when the retrograde material is placed against another metal that is dissimilar, and now we're in the periapical tissues, and we have blood and fluids, bodily fluids.

    We have a battery. Oh, we have a battery! And we have voltage, and we can have degradation and corrosion and tattooing. So, let's look at another angle because one would not be sufficient. And now, you begin to get it. The post really isn't going up the long axis of the tooth, is it? Get those three films. You get the CBCT, it's not gonna be very useful here, because you're gonna get scatter and artifacts. Learn to take well-angulated, various horizontally angulated films, so you can really see. Treatment plan for no surprises! So, here's the post, over here. This is the silver point, over here. Probably when the dentist, because of trauma, wanted to put a crown on the tooth, he probably felt he needed to secure that crown to the root via a post, so he did a core buildup.

    But his post is -- he -- when he -- his drill path, he bounced off the silver point, big silver point! A very big silver point! All right? Very big. He glanced off, and he's deviating, and now you can tell that post isn't even centered in the root. So, if you begin to think about all of this, obviously, you could take the crown off. You can take the post out. You can take the silver point out. The retrograde, you probably couldn't get out. You might have to push them through. We could do all that. All of that's discussed. Risk versus benefits, what can take us to the best prognosis that has a reasonable chance to work over the years ahead?

    Well, wait a minute. This patient came in to see their general dentist because no pain, no swelling, nothing. They said, “There's a big, black mark up in my gum. And if I lift my lip -- lift my lip -- I see blue.” And they had had a relative die of melanoma. They were very, very concerned. So, when you see this, you have to think about the battery. And I've seen many, many tattoos intraorally. You can't get rid of these by treatment. You can get the -- the sinus tract. You can get that to heal because this is draining out facially. But you'd have to have a periodontal -- periodontal, like a surgeon, like a tissue -- vascular type surgeon that can slide stuff around like a pedicle. You might be able to obscure that or minimize it. Fortunately, there's not a real high lip line, so you don't really see it.

    So, there's the crown. We're working on this crown. You can see the margin of the crown, virgin teeth pretty much. Oh, there's a little filling, right in here -- right in there. But virtually, I went in, lifted the flap. There was no bone over the root. So, curettage and clean out the crypt. You can see it's also tattooed and stained. You can see all this blue stuff in here. So, the post is coming out of the root. It's coming out. Well, in the other case, I went like this and made a slot prep. That's how I got it. In this case, I made a pilot hole, and we used a pilot. Just drill right through.

    You're gonna go perpendicular to the post, right across the post, and the post will be tucked back inside the root, and that reserves root. Because I could take it down to there, but now, you're starting to look at this. You're going, “Wait a minute. There's no more root left.” So, this is adding about 30 percent of extra surface area for bone to grow in to keep the root strong. So, I can save root length. You can see I have a nice apicoectomy. I have a nice retro prep. And then, I've come in through here with my Transmetal, and I've gone right across that post, just boom! Right across it, cut it off. Cut it off. And by cutting it off, then I've made myself an opportunity to fill.

    So, I have an apical retro prep in, and I have a lateral repair. And we can get into another lecture another time about membranes. And you can use a little citric acid on this exposed root. You can use it on a pellet, and that'll expose fresh collagen. Put the tissue back down, even if it's tattooed, blue tissue. It will reattach. I don't do a lot of the membrane stuff that everybody loves to do. They like to bring the shopping cart in, you know, and get a little bit of everything in there, and they feel so good after surgery! They can think about a very big -- I can build this out, very big bill. You know, I used everything.

    I'm kidding. I'm kidding. Come on! Gotta laugh! Remember, the show's supposed to inspire you. You're supposed to laugh a little bit, you're supposed to learn a little bit, and you're supposed to look at post-ops, so we can get out of here. They're telling me to get out of here. I can hear it in my ear. “You're over”!

    So, there it is, immediately post-op, and here it is, ten years later. So, you can see the inevitability of the bone to come back in here and repair when we remove the etiology. And when we have done that, the pathogenesis is now eliminated, and the bone will do what it does best, and it knows what to do, and you will have happy patients, the referrals will be happy, and people will be walking around with their teeth.

    CLOSE: What Does Phyllis Think? – Boating Excursions

    Lisette

    Okay. So, it's time for another installment of "What Phyllis Thinks." And we've learned a lot about what Phyllis thinks over the seasons. We have gotten special insight into my dad. We have found out what Phyllis's favorite books, movies, and music are. We have gotten her take on health and fitness, quarantine life, camping, her animal connection. And we've learned all about the Ruddle family close calls, both the ones that were related to human error and then the ones that were because of Divine intervention. So today, we are going to talk to Phyllis the sailor, and we going to find out what Phyllis thinks about all things boating. So, thanks for joining us, and are you ready?

    Phyllis

    I'm ready.

    Lisette

    Okay. The first question is, we're gonna start with little Phyllis as a kid in Michigan, where there are many lakes, both big and small. So, what kind of boating adventures did you have, and what did you think of the experiences?

    Phyllis

    Well, probably my first boating was -- I was young, eight, nine years old. My dad did a lot of fishing. He was quite the fisherman. And he would take us out in a -- just a little rowboat, to catch fish for our dinner. We did a lot of camping on lakes. And I -- it was with the poles. It wasn't with anything fancy. It was just with a fishing pole. And I remember sitting there and waiting and waiting and waiting. It was very peaceful, and we always caught fish. The most exciting part is when you catch it in the net and bring it into the boat and then later, cleaning. And -- and we fried them up and ate them. So, that was my first boating thing.

    And then, I got into canoeing with the summer camp stuff. My dad, again, was in -- in charge of that. And there's some rivers in Michigan that are quite exciting for canoeing. And learning how to canoe and the person -- it's different from kayaking, because the person in front, you just have one paddle. You don't have the double. And so, first, you have to be stuck in the front, because all you can do is paddle. You don't get to know what's going on in the back. And then, learning how to actually steer the canoe and all of that. And some exciting things on one of the trips, we had -- there was a couple that brought their little dogs, little, tiny, yappy dogs. And my dad was so upset.

    And sure enough, the first bend, they got their canoe under the log, and it tipped over, and the dogs were trapped under the log. And my --

    Lisette

    [laughs]

    Phyllis

    -- my brothers jumped in and saved the dogs and saved the people. And it was quite exciting.

    Lisette

    [laughs]

    Cliff

    Wow, Phyllis, the rescuer.

    Lisette

    Well, when did you first sail in a sailboat, and how difficult was it to learn?

    Phyllis

    My first sailboat was with him. I think it was before we got married, but it might've been right around that time. And -- and there's a lake in -- in Oakland, where we were living at the time, Lake Merritt. And they had these little tiny -- as big as this table -- little tiny sailboats. And you had to sign that you knew how to sail.

    Cliff

    [laughs]

    Phyllis

    And he said, Oh, yeah. No problem.” So, we signed [laughs], paid our deposit, and got in this little tiny boat, and there's the sail, and there's a -- the paddle thing that keeps it --

    Cliff

    A keel.

    Phyllis

    -- the keel, that you just stuck in the middle, and you take off. And it was like this wonderful, beautiful, sunny --

    Cliff

    Downwind.

    Phyllis

    -- sailing downwind.

    Lisette

    [laughs]

    Phyllis

    I thought, “Well, this is really fun.” And then, we had to get back.

    Lisette

    [laughs]

    Phyllis

    We're going, “What happened”?

    Cliff

    Upwind. [laughs]

    Phyllis

    We're turning around, and it didn't go.

    Lisette

    [laughs]

    Phyllis

    And I suddenly realized, neither of us knew how to sail. We had no idea the tacking, getting the wind. So, we -- on the shoreline -- we had to be back by 5:00, and we pulled on the weeds all the way back --

    Lisette

    [laughs]

    Phyllis

    -- along the shore to get back [laughs] to where --

    Cliff

    It was a very, very pathetic experience.

    Phyllis

    [laughs] So, we realized very early on we needed to take some lessons.

    Lisette

    And did you, or did you just --

    Phyllis

    We did. We started taking some lessons down at the Oakland Marina.

    Cliff

    Mm-hmm.

    Phyllis

    And they had sailboat lessons you could take. You went out with somebody, and they -- and we started learning about the wind and, you know, all of that. So --

    Cliff

    Yeah. She even learned man overboard drills, except she forgot I was in the water, and they sailed off [laughs].

    Phyllis

    [laughs]

    Lisette

    Well, have you ever been sailing in a storm?

    Phyllis

    A couple of times. The -- the biggest one was probably on Lake Tahoe. And if anybody's ever been to Lake Tahoe, you know how the weather can change on a dime. You just -- you never know. Those mountains, it can happen so quickly. And we were with your sister and family. So, there were four children --

    Lisette

    I remember this, myself. [laughs]

    Phyllis

    -- young. And I was the only one who could be down below without getting sick. And so, the other three adults were up above. And we sailed down to the end of the lake, no problem, kept seeing these gorgeous clouds in the distance. And all of a sudden, the wind came up, it got dark, and we had to take the sail down and come all the way back to where we started with just the little motor going, through huge waves.

    Lisette

    [laughs]

    Cliff

    Mm-hmm.

    Phyllis

    Tahoe's like an ocean when the big storms come. And then, crash! And I -- I mean, I thought we were all gonna die.

    Lisette

    [laughs]

    Phyllis

    And all -- I have all the little kids, and we're just hanging on. And it's just like, we made it back. But that was the most sudden storm that I've been in.

    Lisette

    Okay. You -- you have another one, though? You were in another one?

    Phyllis

    When we went to the BVIs, that sailing trip, it wasn't so much a storm. It was winds, though.

    Lisette

    Okay. So, she's talking about the British Virgin Islands. And in the 1980s, you went on a sailing trip there. And I think you guys did bareboating, which is where you are the crew and the cook?

    Phyllis

    Yes.

    Lisette

    So, can you tell us briefly how it came about that you even had this experience, and how you prepared for the trip, and maybe share an adventure that's related to the Sir Francis Drake Channel?

    Phyllis

    [laughs] We have good friends that he met in dental school, one of his classmates. And they wanted to do -- they were quite the sailors. They live in Reno area, and they would come down to the Bay Area and do a lot of sailing. And so, we -- we would do that with them and had fun. They knew we liked sailing. And so, they had this great idea to go bare -- bareboating, which means you'd better know all of the ways -- everything you need to know to do sailing. So, we took some classes in the Bay Area, on the Bay.

    And all I remember is, it's freezing cold to sail on the San Francisco Bay. It's always cold. It doesn't matter if the sun's out. And we had to learn how to anchor. That's a huge thing when you go bareboating anywhere. You have to be able to anchor. And that was one thing we had never done. You go into a harbor, you hook up to the whatever. But when you go bareboating, you have to hook up out in the water. You can't --

    Cliff

    There's a cove.

    Phyllis

    Yeah. There is no dock [laughs]. So, we did that with them, a couple of trips up there. And it's funny, because in retrospect, I realize they picked us because they knew we would be up for the adventure. They have -- we've never gone back. They have gone back many times and hired a crew, and they go --

    Cliff

    [laughs]

    Phyllis

    -- on a really big sailboat, and they just relax the whole time. They have never again gone and done their own sailing, like we did with them.

    Cliff

    We were on about a 60-footer.

    Phyllis

    Yeah. It was a pretty big boat.

    Cliff

    But they went back and got on 90-footers. [laughs]

    Phyllis

    Yeah. They went back with other -- other friends in their group and didn't have to do all the cooking and sailing. So, that was the start of our big trip. And so, then we flew down there, had to ration the, you know, the ship and all that stuff. We had to have a -- an instructor with us for a few days to prove we could do all of the things you do. And you just go from island to island. It's -- it's very peaceful and magical, except we had high winds. It was right during the beginning of hurricane season. And they kept talking -- all the other people around kept talking about the possibility of a hurricane, and we're thinking, “Well, you know, where is it”?

    Lisette

    [laughs]

    Phyllis

    Anyway, we didn't have a hurricane, but we did have high winds, 30-knot winds, 24 hours a day, the whole week we were sailing. And that's a little hard when you're trying to sleep and your boat's just mm, mm, mm, mm, in the water, and it's like [laughs] are you gonna still be anchored in the morning?

    Lisette

    But there was a storm?

    Phyllis

    At the -- the very last day, there was a storm. And as we were coming in, you could see the clouds and the wind and all -- it was quite exciting, the -- the lightning. So, it was good we were coming into harbor on that very last day. And then, that evening we ate in a restaurant -- outdoor restaurant with the big storm around us. So, that -- that was a-- a storm on the trip.

    Lisette

    Well, what about -- I know you tell a story where you were down below, and then, something happened, and all of a sudden, you were out of the sheltered island area and out in the ocean?

    Phyllis

    Yes. We -- we went out of the Sir Francis Drake Channel.

    Cliff

    Right.

    Phyllis

    And I was down fixing lunch, because again, I'm the only one that doesn't get seasick. And so, I get sent down to do the -- the lunch stuff and all of that, and they're all up above. And you're supposed to always yell out when you change directions.

    Lisette

    [laughs]

    Phyllis

    Well, when they went out into the ocean part, there was suddenly, I don't know, maybe 50-knot winds. It was just this incredible blast of wind.

    Cliff

    Big seas.

    Phyllis

    Big seas. And they came about suddenly. The mainsail ripped. Well, I'm down there fixing the sandwiches, you know.

    Lisette

    [laughs]

    Phyllis

    I'm -- not even knowing there's a problem. And all of a sudden, I am thrown across --

    Cliff

    The galley.

    Phyllis

    -- the galley and I’m rolling around. I end up under the chart table when it's finally all done.

    Lisette

    [laughs] Geez.

    Phyllis

    Then, I'm laying there thinking, “Is anything broken”? [laughs]

    Cliff

    We're hungry. Come on! Get those sandwiches up on board. Come on, you got a crew up here. [laughs]

    Lisette

    [laughs]

    Phyllis

    It was quite amazing. Quite the adventure. I just had bruises. Nothing broken, but some of the bruises lasted a good six months. [laughs]

    Lisette

    [laughs] Okay. Well, now, you also went on a river rafting trip in Colorado. And I remember just -- as I was, you know, growing up, I remember always seeing this picture.

    Phyllis

    It's a big one.

    Lisette

    I think we have the picture still. So, hopefully, we'll show it.

    Phyllis

    Yes.

    Lisette

    What did you think about this experience, river rafting?

    Phyllis

    That was fun. It's a little bit -- I actually like canoeing better, because there's, what, eight people, ten people in a raft? So, you're all kinda packed in, and you all have an oar. And it was fun, but you see these rocks coming up ahead. And there's always somebody that's running the thing. You don't get to just take it yourself.

    Cliff

    Yeah. And like a raft --

    Phyllis

    Yeah.

    Cliff

    -- or a canoe, there is a guide.

    Phyllis

    That -- with you. And so, you're coming down, and you see what's coming ahead, and it was quite exciting. We had a good time. It was in Aspen area, and I remember it was very exciting. Nobody fell over or anything like that. But some of the rafts, they did.

    Lisette

    Was that multiple days you went? Like --

    Phyllis

    Just one.

    Lisette

    -- oh, one day?

    Phyllis

    They take you one place, and you go down, and they pick you up.

    Lisette

    Oh, okay.

    Phyllis

    So, yeah.

    Cliff

    She'll tell us on another segment about the waterfall.

    Phyllis

    Okay [laughs].

    Lisette

    [laughs] Oh, God. Have you ever been on a cruise, and if not, would you ever want to?

    Phyllis

    I have -- have always wanted -- I've never been on one, and I've always wanted to. I've been on a lot of ferry boats over the years, and I just think it's so magical to be in a little cabin and -- not internally, but I wanna be with -- one with a window, and just -- it just seems like such a romantic thing. But no, we've never been, and I -- I don't think I will ever get him on a cruise. Maybe the Alaska cruise. That might be the only one that -- that he would be interested in going on.

    Lisette

    Penny, a friend of theirs, always talked about -- well, I -- her cruise to the Antarctica and seeing the penguins and stuff.

    Phyllis

    Yes!

    Lisette

    And that was amazing.

    Phyllis

    Yeah. And she goes on smaller ones, where there's only maybe 100 people. It's not like the ones we see come into the harbor, 3,000.

    Cliff

    And she can be gone for three months at a time.

    Phyllis

    Yeah. She's on a cruise right now. Yeah [laughs].

    Lisette

    Oh, okay [laughs]. Well, let's finish up by you telling us what you like most about boating and maybe what you like least, and maybe also if you've -- if there's any lessons that you've learned by -- from boating.

    Cliff

    Mm. Lessons, Phyllis. Lessons.

    Phyllis

    Well, the lessons are, tell people when you're going to come about.

    Lisette

    [laughs]

    Phyllis

    That is the number-one lesson I learned. And that wasn't my fault. I prefer a boat that stays upright. I'm not a big, you know, the whole sailing back and forth thing. I -- I really like the -- the bigger boats that are like a living room, and you just sit there. [laughs]

    Lisette

    [laughs]

    Cliff

    She likes to motor sail, versus wind sail.

    Lisette

    She likes yachting. [laughs]

    Phyllis

    I like yachting, yes [laughs]. So, just working as a team. You have to learn all of the different things, you crank, and all that stuff. I mean, it's -- it's a lot of things to remember.

    Cliff

    She's a winch woman.

    Phyllis

    Yeah. It's a lot of things, and --

    Lisette

    [laughs]

    Phyllis

    -- you know, amazingly -- and then, coming into a -- a harbor. We used to do some early sailing with his sister and brother-in-law, down in San Diego. And that was where I learned about -- what do I call it? Oh, talk like a sailor --

    Lisette

    Oh [laughs].

    Phyllis

    -- from his sister.

    Lisette

    Oh [laughs].

    Phyllis

    Yeah. Every time we had to come in -- and in those days, you didn't have a little motor or anything. You had to sail very deftly and get into your space --

    Cliff

    Your slip.

    Phyllis

    -- without hitting any other boats. And it would be like, quite exciting with Carolyn and Joel --

    Lisette

    [laughs]

    Phyllis

    -- getting into their slip without damaging any other boats or their boat.

    Lisette

    [laughs]

    Cliff

    [laughs]

    Lisette

    Okay. Well, thank you for sharing all of that information about boating. I thought it was really interesting.

    Phyllis

    It was -- it's fun. We have great experiences. I have to tell you something funny. When we go on a trip -- I live with a romantic. And when we go on a trip, and then people hear us talking later about a trip, they think we went on different trips.

    Lisette

    [laughs]

    Phyllis

    Because he remembers the little picnic on the beach, the little dinghy going in, the -- the pelican diving, you know --

    Cliff

    Frisbee, snorkeling, come on!

    Phyllis

    -- you know. This is -- these are all top of his list.

    Cliff

    Catch of the day.

    Phyllis

    I remember rolling around down there in the galley --

    Lisette

    [laughs]

    Phyllis

    -- trying to survive.

    Lisette

    Well, it's actually kind of funny, because when I told Dad that we were gonna do this segment about boating --

    Phyllis

    [laughs]

    Lisette

    -- he starts immediately telling all of these stories about your boating trips.

    Phyllis

    Picnics on the beach.

    Lisette

    And I'm like, “Well, yeah, Dad, but Mom's gonna be telling it.” And he goes, “Well, Phyllis can't tell stories.”

    Phyllis

    [laughs]

    Lisette

    But [laughs] --

    Phyllis

    He tried to prep me ahead of time, and I just looked at him. Yeah. I have my own stories.

    Lisette

    [laughs[

    Cliff

    Well, you know, I guess I should tell my camera that -- who goes below deck to make sandwiches in the eye of the storm? Really?

    Phyllis

    [laughs]

    Lisette

    [laughs]

    Cliff

    Really.

    Phyllis

    But we were hungry!

    Cliff

    Oh, yes.

    Lisette

    Okay. Well, that's "What Phyllis Thinks," and that's our show for today. Hope you enjoyed it. I just wanna say to you all, please, if you wanna comment on anything we talked about in the show today, do so. If you wanna tell us what your person -- who your person of the week is, if you have to share any boating experiences, or --

    Phyllis

    [laughs[

    Lisette

    -- or maybe you wanna comment on the surgery segment or "Knowing the Difference," feel free. We love your comments. So, please comment.

    Cliff

    Thank you, VK.

    Lisette

    [laughs] Okay. See you next time on The Ruddle Show.

    END

    Disclaimer

    The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.

    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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