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 the vast majority of dentists do not know the status of the pulps within the teeth...
Endodontic Diagnosis & The Implant Option Vital Pulp Testing & Choosing Between an Implant or Root Canal
Which tooth is it? This show will review how to perform vital pulp testing utilizing hot and cold to aid in correctly identifying the culprit tooth. Additionally, Ruddle will discuss the pros and cons of deciding between an implant or root canal treatment. Stay tuned to the close of the show where the bloopers will have you laughing out loud!
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Ruddle on Shape•Clean•Pack
This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. Today for our show, first my dad is gonna give you a little review on how to do vital pulp testing, using hot and cold stimuli. And then, after that, we’re gonna talk a little bit about the pros and cons of implants versus endo. But to get started, first we’re gonna talk about something that’s probably affected everyone, at some point in their lives, either directly or indirectly, and that’s snoring. So, yesterday, my dad showed me this really funny cartoon, and let’s get it up here. Okay.
So, here, in the cartoon, it says, at the bottom, ‘Snore-Be-Gone, Anti-Snore Mattress’. And then, you can see that apparently there was a snoring issue. This woman here pulled the lever, and then, she solved the snoring problem.
So [laughs], I guess, apparently this ad, or this cartoon has been used in a lot of places. And maybe you’ve already seen it. But I do know that also a mattress company uses it [laughs], too. So, that’s kind of funny, I thought. But first, why don’t you tell us, like, what is happening to somebody, when they’re snoring?
Very good. Well, first of all, apnea is a potentially serious sleep disorder, where you actually can start and stop breathing. Now, the physical, mechanical issue would be primarily in your soft palate. And in the soft palate, it – when you relax and get into a reclined position, the soft palate can actually fall down, a little bit. So, if you have a normal airway, and air’s going in and out, breathing normally, well, when you start to close this aperture, because of restriction from the soft palate collapsing, it can start to be like a Venturi effect, and it can change noises. It can be anywhere from a very minor nuisance to where you have to use the lever.
[laughs] You had mentioned that, when you go and lecture at various venues, that always there’s somebody there lecturing about snoring.
Yeah. It’s interesting. It seems like in almost all the venues I’m at, in the last five years, you will absolutely find clinical speakers, speaking about its causes and the remedies and everything in between. I happened to be lecturing at Seroworld 2016, I believe, and there was 7,500 people in the audience. And the woman before me gave an enlightening one hour on sleep apnea. So, you’re right. We’re seeing this come more and more into the mainstream, and probably because the news and in social societies, there’s more attention to this. And you’ll get into some of the causes. Maybe you can start to tell us a little bit, what would cause it. I told you mechanically what happens.
But what exacerbates that?
Well, I don’t – well, okay. Well, there are – I had always heard that if someone is snoring, then, you just need to roll them over on their side, and that will solve the problem. And in my experience, that has always worked. [laughs] So, I always thought that that was the number-one thing you do. But then, we found this, “15 Ways to Stop Snoring”, on healthline.com. And it was kinda interesting, because I saw that the first thing on the list, I was not expecting this, was, ‘Lose weight, if you are overweight.’ So, I guess that’s an issue.
Obesity definitely contributes. And I guess we should probably give our audience some feel for the frequency or the – in populations. We have read a range, but more or less half of all Americans snore to various degrees. So, when we start to think about half of all Americans, it means that in my audience today, in our audience, we have snorers.
And I can certainly tell you, sleeping on the side was a really good deal. Second pillow can get your head up. That can be a remedy, right?
Yeah. They said, I guess, nasal strips. You had mentioned that you had sometimes seen athletes wear nasal strips.
Just to get more air, to get – keep gettin’ more air in the airway.
So, is that something that you could just buy at the store? Is it --
-- a drugstore?
Apparently allergies, if you’re – if you have allergies a lot, that can increase snoring. Some people have actually structural problems in their nose, that need surgery.
Right. You know, you should probably restrict your alcohol consumption and probably cut back in moderation to a bottle a night.
Oh, I mean maybe a glass a night. I’m sorry. I got off on a [crosstalk] bottle [laughs] or a glass. Probably a glass. But excessive alcohol, you can see how these things are synergistic. Now, you’re overweight, I’m saying, potentially. Now, maybe you’re sleeping [laughs] pretty much flat. You’re on your back.
It says smoking causes – and you’re smoking [laughs]. So --
And you have allergies. So, you can start to see how these not only are singularly, but synergistically, they can play a bigger role. Now, there’s a lot of things Lisa and I just talked about, where there’s sort of remedies you can do at home. Problem recognized is a problem half solved. But there were other --
-- yeah. More – things that you would actually go to a physician or a dentist to get some type of equipment, or like – I’ve seen oral appliance. What is an oral appliance?
-- well, they can make – take an impression of your mouth, and they can make fixtures that actually can help hold up the soft palate at night, to maintain that preferable airway. And then – those are more benign. Then, they have positive pressure airway machines that you inhale oxygen.
So, the CPAP, I guess?
Yep. It’s a continuous pressure airway machine that keeps oxygen coming in. So, some people can benefit from that. And then, there’s the uvulopalatopharyngoplasty. This is --
Good job [applauding]! [laughs]
-- where they can actually go in – yeah. That was a tough one. That one’s like something else --
I didn’t even wanna go near that [laughs].
-- but it’s a soft-tissue procedure, where they can reshape and play with the soft palate, to optimize your airway. And they can do that with lasers.
Is – now, a palatal implant, is that different than what you were just saying?
Yes, a palatal implant, they actually – a surgeon would put polyester strips, like fibers, and they would put that in your soft palate. And it’s like a scaffolding to hold the palate from sagging, when you relax. So, that’s another idea. That’s surgery. Then, there’s the laser thing we just talked about. And then, there’s actually radio waves that can be used.
Okay. So, yeah. If you can’t just reduce your weight, reduce your smoking, reduce your drinking, you can go get help from a dentist or a doctor, some – there is more help out there.
Well, I don’t wanna be slapstick, because I know from listening to some of these really fine lecturers, internationally – I’ve actually heard quite a few of them, now, in the last five years. It’s a serious problem, but I guess, to have a little humor, I still prefer the hand on the lever --
-- because it seems so effective to pull the lever. And if you have your fingers and hands on the levers and dials, you can usually manipulate things.
I’m worried. Do you have a lever? [laughs] Am I okay?
I don’t think I snore. Do you snore? [laughs]
[snoring noise] Well, I think when you ask people if they snore, I would say, ‘I definitely don’t snore.’ But Phyllis might have another opinion.
Does Mom snore? [laughs]
Oh, prolific snorer.
[laughs] And just to close, how does snoring differ than someone like Lori, our – my sister, who laughs so hard that she makes sort of snoring noises? [laughs]
Well, when she gets laughing really hard, she’s playing with that available space in her throat and her airway, and she’s affecting the air that comes in, and the sounds.
When she does that, it makes me laugh twice as hard.
Okay. So, let’s get started with our show today. I think you’ll find it enlightening.
SEGMENT 1: Endodontic Diagnosis – Vital Pulp Testing
You’re all really good at finding the toothache, aren’t you? [laughs] Yeah. Dentistry’s very good at finding the toothaches. But that’s not why we’re here together. If you’re with me today, we’re here to find asymptomatic teeth that are irreversibly, pulpally involved. There’s a lot of that out there, and a lot of dentists are working on teeth, they’re making crowns and castings, prepared – on prepared teeth, and they have no idea what is the status of the dental pulp.
So, obviously, if we’re talking about a comprehensive endodontic examination, we would gather the clinical findings. In another segment, I’ll show you some pretty interesting pathologies and various things that are not always seen every day, but it’ll get it on your radar. And then, we’ll go into a lot on our radiology exam, the CBCT, the digital radiography, all the different assets that we can use for a complete, comprehensive diagnosis.
So, today, we’re gonna specialize on vital pulp testing. And there are four vital pulp tests. There is the cold test, there’s the hot test, there is the cavity test, and then, there is the electric pulp test. I don’t think you’re using that. Oh, yes, some of you are. My mentor taught me, back in the ‘70s, he never used the hot – the electric pulp test. And when he did, he only believed it when he felt current going up his arm. And when his shoulder started to burn, he realized it was a bad tooth. Okay. It’s a joke!
The point is, we don’t do electric very much, because there’s no place to put the electrode, because most teeth are heavily restored when they get to an endodontist. So, when we have heavily restored teeth, we can’t find cementum or dentin to put the probe metal on. So, I’m down to doing what patients actually report. They report cold symptoms. A cold drink might stimulate it. And they’re also gonna report, oftentimes, heat, coffee, tea, foods. So, we’re gonna try to reproduce the chief complaint. It’s really important to talk to our patients, focused on that, and they’ll tell us an awful lot of information that we need to know, if we bother to listen.
Oftentimes it says, Doctor, we jump into that room and we start tellin’ this, ‘I see that. I see that.’ Wait a minute. Zip it up, and say, ‘What brings you to me today? How can I help you? What’s bothering you? I sense you have a problem.’ And they’ll start to talk. But you can steer it, so it doesn’t go everywhere, and you waste an enormous amount of time. So, get the chief complaint. Now, what we’re trying to find out, when they report cold, we would want a cold test. If they tell us they’re having problems with heat, we’re not running a cold test. We’re running the hot test. If they say, ‘Hot and cold really isn’t an issue’, we run the cold test, because it’s simply easier, and it’s very reliable.
Now, about these various tests, if you’re doing them over and over, endlessly, you get really, really good. And even when the test gives you false positive, you know it’s a false positive. So, I’m thinking that pulp tests are highly reliable, if we bother to do it and get a baseline. When you’re doing a test, you’re looking for the immediacy of the response, the intensity of the response, and the duration. And out of those three, the duration is the one that stands up and says, ‘It’s me. I’m the culprit tooth.’ So, if you just had a periodontal procedure or a new restoration yesterday, everybody will say, ‘I feel it’, immediately.
They might say, on a scale of 0 to 10, 0’s perfectly fine, 10’s the worst they can imagine, they might say, ‘It’s a 12.’ Okay? But if it goes right away, it’s transient, then, that is a pulp that’s inflamed but not necessarily is it irreversibly involved. So, let’s go forward. How do you get the baseline? How do you get the baseline? I’ll bring these in. If the lower right quadrant has a talking point today, in this little segment, if this is where the patient’s complaining of a problem, don’t come at them with cold. In other words, they say, ‘Cold’s killing me.’ And you go, ‘Ice!’ And you come right at ‘em with the ice, and they’re going, ‘My God, he didn’t hear me. I said, “It’s killing me to ice.”’
So, tell them what you’re going to do. Pave the way with words. Communicate. Say, ‘Are you okay, as far as you know, with cold on your left side?’ And if they say, ‘Yeah. I haven’t had any problems, just over here’, then go, ‘What I’d like to do is establish your baseline for what’s normal for you, so you don’t fool me, and I don’t fool you. We want good information.’ So, what you would do is, you would get this baseline by going to contralateral teeth. You could go upstairs, opposing teeth, above the lower right quadrant. And finally, if there’s a culprit tooth in here, do all the other teeth that you suspicion are okay first, doing the culprit tooth last. So, that’s our sequence, okay?
Now, how do you run the cold test? I understand there’s many different ways to apply cold. Cold is nothing but energy. So, you know, we have energy on the Y axis, and we have time. And if we use ethyl sprays, we’re gonna find that when we go from tooth to tooth to tooth, not every tooth’s getting the same energy. So, we’re not getting good readings. I like to use an old-fashioned test. It’s called an ice pencil. What we do is purge. We purge all of the anesthetic out of a virgin carpule. When the carpule’s empty, we simply cut dental floss and stick it in the hole, in the carpule, so that it’s about one inch or two inches longer than the carpule. Now, fill that carpule with ice.
But wait a minute. You’re not about one patient. You’re gonna see lots of people that have problems with cold. So, you might fill up six, eight, nine of these, put them in a cup, so they can’t fall over, and drain. Put ‘em – open the refrigerator, and put ‘em in the freezer compartment, okay? The freezer. Could be down below, too. And then, you’ll have ice on demand. When you need ice, let’s watch how we free this up. Roll it vigorously between the gloved hands. The palms will warm up the ice. Grab the floss and pull out a pencil of ice. Now, this ice is laid in a two by two gauze, so that your fingers don’t prematurely melt the ice, and you suddenly lose your ice pencil. Okay?
But remember, you have more in the freezer, right? Okay. Now that we have a little ice going, and we are holding the gauze so that we can have control, we have a lot of control, let’s go to the mouth. First, I would like to talk about hand signals. It’s really important in vital pulp testing that we communicate with people. So, it might go like this. ‘Mary, when you first feel the sensation of cold in your tooth, raise your hand, and that’ll alert me that you feel cold in your tooth. Okay? If you must speak, ask a question. Okay?’
And they’ll go, ‘I didn’t quite get’ – ‘Mary, when you feel cold in your tooth, could you just raise your hand. That’ll alert me you feel the cold. Does that make sense?’ ‘Oh, yeah. I got it! That [inaudible]’. Okay. ‘Keep your hand up, as long as the cold sensation lingers in your tooth. Does that make sense?’ Okay. ‘As long as you keep feelin’ it, keep your hand up. And then, lower your hand when the sensation dissipates and goes away. Are we good?’ And then, you start the baseline. Because they’re not good, but they’re gonna say they’re good. So, on the first tooth, on the contralateral side, you start movin’ the ice back and forth, and you notice they’re levitating right out of the chair. I mean, they’re squirming. Okay?
And you go, ‘Oh, gee, I sense you felt the cold.’ ‘Yes, Doctor, I forgot to raise my hand.’ Good. So, repeat it. ‘Raise your hand when you first feel the cold. Keep your hand up as long as you feel the cold. Lower your hand when it goes away.’ [Speaking rapidly] Go to another tooth. They’re locking it. Now they have their hand up for a couple hours, and you’re sitting there, sleeping, probably snoring, like the early segment of this show. [Makes snoring noise] ‘Did you really feel it? It’s two hours later.’ ‘Oh, I forgot to lower my hand.’ So, repeat. ‘Raise your hand when you feel it. Keep it up as long as you feel it. Lower it when it goes away.’
About the third or fourth tooth, they’re getting totally locked in, and you’re establishing a baseline that’s very reliable. We’re not comparing Mary to Sam or Peter to Joe. We’re comparing similar teeth in the same mouth. And most mouths are about uniformly restored throughout. It’s rare to find all virgin teeth and wall-to-wall crowns, unless there was an elbow in the paint, in basketball, a hockey stick, a car accident. But normally, mouths, if you find a few crowns on this quadrant, you’ll find a few crowns and more crowns and crowns. So, we’re gonna get a good baseline. So, that’s the hand signals. Check!
The next thing is, how do we do it? Well, you gotta have the assistant have a locking plier with a cotton pellet, and she goes distal. She goes into the embrasure, distal to the tooth you’re gonna check, so the ice doesn’t run back onto the more posterior tooth, and you provoke a false positive. Okay? So, the ice will run into the cotton pellet. It’ll insulate the more posterior tooth, and you’re gonna be golden. Now you’re gonna wiggle that ice back and forth, cervically, right close to the free gingival margin. That’s the closest distance into the pulp. It’s where the enamel is thinnest. It’s where our restoratives are thinnest. And that slurry of water will begin to bathe the tooth.
It'll conduct, it’ll penetrate and will get energy in, to stimulate a pulp, if it’s alive. Because if it’s a necrotic pulp, there’ll be a no response. If it’s a hyperemic pulp, really engaged with – engorged with blood, you’ll get an immediate response, and they’ll pull away, and their hand’ll up, sometimes maybe a minute. So, remember, intensity, duration – intensity, immediacy, and duration. Duration is the one that separates out the good pulps from the bad pulps. So, here we are, cotton pellet protecting, and now, here we go. So, you’re wiggling that ice, you’re getting a little bit of bathing. The hand goes up. It’s not so remarkable.
The cotton pellet comes forward. Now you do the more anterior tooth, in front of the pellet. Get another hand signal. And you can keep doing this, and you can go around the horn, and start to establish the baseline on the patient. Make a cold slurry. That one was kinda painful for her. The response lingered, and it lingered, and it lingered. And that was her chief complaint at home. She had sensitivity, she called it ‘pain’, to cold, that lingered. So, after she swallowed, the pain was still there. So, if you begin to cold test, even heavily restored teeth, usually you can find a metal collar on the lingual, like on the porcelain fused to metal castings, and that metal’s a great conductor. So, go on the metal, on the inside.
I know you’re gonna say, ‘Oh, these jackets, these porcelain jackets, these porcelain fused to metal crowns, they have a lot of insulating material.’ Go close to the free gingival margin. In fact, as a little tip, you might put the ice and smooth it back and forth on the free gingival margin and say, ‘Do you feel that?’ And they’ll say, ‘Yeah. That’s cold, but it’s not sharp.’ Pulpal is more sharp, but it’s transient. I hope you’re getting some information that’ll help you find diseased pulps, hyperemic pulps, necrotic pulps. Okay. What if they complain of something different? It’s not cold. They come in, and it’s tea or coffee.
You can use a number of devices in industry. Dentsply Sirona, Tulsa Dental in the United States, My Fair overseas, makes the Calamus unit. The Calamus is made for warm gutta-percha techniques for fitting the cone, down packing, back packing. It has a heat side and a gutta-percha squirt side. But if you come into the continuous mode, you push this mode, and you immediately then will have this tip start to get hot. You can take a gutta-percha cone or a piece of a cone, and the thermal energy in that tip will begin to thermal soften that gutta-percha. We would never put a metal tip directly on a casting or a crown, because you’ll – if it’s a jacket, you could actually blow the porcelain right off the metal [laughs]. Whoops! So, anyway, you don’t want that to happen.
Besides, the warm gutta-percha, it’s soft, and it’ll adapt very nicely to the contours of a tooth. So, you get good conductivity and penetration into the dentin underlying the casting. So, this would be a quick way to run the hot test. I might ask you to ask a couple questions. This is important stuff. I know you’re listening very intently. You’re just riveted to my next words. Ready? Ask the patient, if they’re drinking coffee, does it – does the sip of coffee – is it provoked – is the pain provoked on the first sip? If you ask a more intelligent question, you’ll get a little better answer. Because a lot of times, they’ll say, ‘You know, I never thought of it, but it’s not the first two or three sips. I’m – geez, I’m way down inside that coffee, and all of a sudden, it’s killin’ me.’
Well, then, don’t think you’re gonna put a thermal softened gutta-percha that’s hot on the side of a tooth, necessarily, and provoke it. You might have to keep it there a little longer to build up to the threshold that triggers the pain response. Okay? That’s a good trick. So, we’re ready to take this to the mouth, and you’re in the continuous mode, and that means it’s just running, and you can go from tooth to tooth. Sometimes we have to take this off the tooth and make the ball a little bit more mushy, so when we press it on a tooth, we have gutta-percha, and we don’t press through the gutta-percha and have the metal contacting the restorative.
So, here we are, hand signals, ‘When you first feel heat in the tooth, raise your hand. Keep your hand up as long as the heat lingers. And lower your hand when the sensation dissipates and goes away.’ Again, you have to say these things a few times. Again, you need to go to contralateral teeth, adjacent teeth, get the baseline. But when you look clinically, and you see the dark tooth, I guess I will show that again. This was a hands-free roof, so it was a very clever up here. I want you to know, when you see a discolored tooth like that, that’s necrotic. And a necrotic tooth oftentimes has bacteria. Bacteria produce gases. And when you elevate the temperature, gases infringe on the nerves, and that transmits to the brain, and those can be big toothaches.
And sometimes the pain that is elicited from heat is turned off with cold. So, have some cold ice around, or have the triplex syringe and the high-speed suction, so if you precipitate a big pain response, this isn’t [makes loud ‘Sshh’ noise], she can hit that tooth with water, turn the pain right off. That’s highly diagnostic. Stimulate the pain with heat, turn it off with cold. Okay. So, dark teeth, trauma. That was an etiology. I’m not showing you the radiographs today. We’re just looking at how do we do vital pulp testing?
So, we’ve done the hot test with thermal softened gutta-percha, and we have not reproduced the chief complaint. What do we do? There’s another test. It’s very, very good. It’s a little bit time consuming. And you have to be careful, because you have to isolate the tooth. So, we don’t say to the patient, ‘If you feel anything, or if it is tight or something, raise your hand.’ Just say, ‘If I exceed your comfort zone, raise your hand. You’re in charge.’ And then, be your word. If they’re in charge, they are in charge.
So, what you do is, you isolate the tooth without anesthesia. You’ve gotta get the prongs or that clamp. You gotta get those prongs on tooth structure, not on free gingival margin. That hurts. But you can do this, and it just take a little bit of time. So, make time, so you can isolate teeth. Now, we mostly all have coffee in our offices, so use the hot coffee water that’s used to make the coffee. Use hot water, and you can syringe hot water right onto that tooth. Instead of getting more of a point contact, like the thermal softened gutta-percha, the hot water’s gonna begin to fill up the dam, and the tooth’s isolated. So, you’re gonna really bathe that tooth more circumferentially than you otherwise would.
So, here’s how that might work. Just start squirting. Notice the eyes, everything’s fine. This is a very delayed reaction. There’s a lot of water on that tooth. And finally, we build up to the threshold, and you can see the furrowed brow, you can see the hand jerk, and I mean, it’s diagnostic. Come right in there with the assistant, cold water, turn off the pulpal pain, and you’re good to go. Pretty powerful diagnostic stuff, huh? So, in this segment, what we’ve looked at is the importance of getting the baseline. We’ve talked about the importance of how to do two of the vital pulp tests, hot and cold, not so much emphasis on electric pulp testing, and the cavity test.
We said, for sure, get a baseline, go to contralateral, opposing, or adjacent teeth. Do the suspect, do the culprit tooth last. And finally, work on those hand signals. And you do that when you’re doin’ the baseline, away from the culprit tooth. And if you begin to do that, you’re gonna find a lot of missed diagnostics. And remember, it’s kinda crazy, when you’re up there cutting on that crown, dentinal dust is blowing through your hair. It’s a marvelous feeling! You really are accomplishing a lot today! And you have no clue what’s the status of that pulp. So, I want you to be a better doctor. I want you to take the time to do this.
In many states of the United States, well-trained auxiliaries, like Registered Dental Assistants, can do these tests for you. Have it all written down in the record, come in and show you in another room, so you’re really clear what’s going on, before you step into the room. Okay. Be a pulp tester.
SEGMENT 2: Implants vs. Endodontics
Okay. So, there has been some controversy over the years regarding dental implants. Should a patient with a failing tooth have the tooth extracted and receive an implant? Or should that patient try to save their tooth and undergo endodontics? Clearly, the treatment of choice should be based on the clinician’s knowledge and experience as well as what is best for the patient. Implants can definitely represent a benefit, but I don’t think anyone wants their tooth needlessly extracted, when it can be saved. So, today we’re gonna talk about implants versus endodontics. First of all, why would a patient ever say that they – well, would a patient ever say that they wanted an implant? It seems to me that most people would wanna save their own tooth.
You’re exactly right. In 45 plus years of practice and being around patients and other doctors, it would be rare to have a patient say, ‘I would opt to have an implant.’ But if you had massive decay, and the tooth is non-restorable, if you had a vertical root fracture, and it’s not salvageable, if you had a tooth that was hopelessly involved, periodontally, those three reasons alone, the patient might want you to save their tooth, but it might not be not only possible but practical. And it might not be technically feasible. So, in that case, it’s better to give them that’s more long-term, it’s gonna last, and it’ll contribute to their health.
Okay. So, you said usually a patient wouldn’t suggest that – an implant. But I know that there are some people out there that think that endodontics is – that it can cause cancer, that it’s – that endodontics is actually dangerous for an individual. And would that person maybe choose an implant because they think it’s safer?
That’s a good point. You and I have done work before. Several years ago, we were talkin’ about Mercola [sounds like], and we were talking about the guy down in Ojai --
-- Meinig, and he was a dentist. And information that they’ve disseminated, although it’s misinformation, almost like malpractice information, it still has got into the public’s sight, and if somebody doesn’t want a root canal, for whatever reason, it’s not our job to talk ‘em into it. So, I missed one comment. I said caries, vertical fractures, hopeless periodontal, how about just the edentulous space?
People will come in and say, ‘Is there some way you can fill this missing space with a tooth?’ And they may not say the word ‘implant’, but they want the missing space taken care of. So, that’d be probably the four reasons that I have seen, over my career, where people get kind of led into implants because it’s wise. It’s a good option for ‘em.
Well, if they have a space, could they just have a bridge?
Absolutely. And of course, with bridges, we have to prepare adjacent teeth, and those teeth may already have restorations. They may be heavily restored with well-fitting crowns that are aesthetically pleasing. And not only then do they lose the investment of those castings, but then, the tooth, a lot of times, has to be re-prepped a little bit. And then, there’s impressions. And these are all accumulated episodes for the dental pulp, and sometimes the dental pulp will not survive repeated episodes of dentistry. So, it can contribute to future endodontic problems.
So, if we can leave the adjacent teeth alone, whether they’re virgin or heavily restored, it’s always in the patient’s best interest, and especially if we can get an opinion that says it’s a good site for an implant or it could be made as a good site, with bone grafts.
Okay. If the prognosis looks good?
What about financially? Are – is one more expensive than the other?
Oh, I’m glad you mention this, because I’m gonna talk about the bad news, and in most human endeavors you’d like me to say, ‘the good news’.
But in this case, I’m gonna say, ‘There’s bad news, and there is the worst news.’ Okay. When you’re doing endodontics, the very essence of what is there to salvage teeth and make sick people well, you’re going to spend probably, like most clinicians with today’s technology, someone around an hour or two hours on a molar. Okay?
For a root canal?
For a root canal. And then, you know, you’re gonna go back to your general dentist, say, within a week. And you’ll get maybe – you – the build-up, or maybe the endodontist did the build-up. But anyway, you’re gonna get the build-up. Then, you’re gonna have the prep, the impression, and provisionalization, and bye-bye. Two visits. Now you’re gonna come back and get – seem impatient [sounds like]. So, if I was wrong, endo could take two visits. The restoration could take two visits. So, in four visits, or in about a month, you’re going to have a result.
And so, you’re paying for the endodontic treatment and the crown?
Yeah. So, the old mathematical expression, a root-canal treatment plus the restoration should equal the alternative, or the alternative could be an implant or a bridge. So, back to the bad news, when you’re doing a root canal, you’re spending more time, and you’re going to be charging less than the alternative. The alternative’s an implant. Implants – yeah. There’s a consultation, there’s a CBCT, there’s some oral imaging. And together, there’s algorithms to – that can take these two programs and put ‘em together, and they can give us, through the X-Nav, a piece of technology that guides the dentist’s hand.
So, you can basically watch on a screen, you have X, Y, Z orientation, and you can place the implant perfectly, where there’s maximum bone, and so that we can have good lobes, so the lobes are not deleterious, hitting the tooth from the side, but coming right up the long axis and distributing the forces up through the implant. So, back to the good news, worse news, to do a root canal, I said would be an hour or two, based on complexity. An implant is 10 or 15 minutes, after the consultation. And then, I have to wait -- for the implant, I have to wait maybe six months for osteo integration, and then, we can put a restoration on that implant.
So, the whole implant procedure, from extraction, bone graft is typical, and then, actually prepping the site, placing the implant, and my guy, Dr. Mark Bienstock, was very, very fine, fine physician.
Because he just recently had a couple implants?
Oh, I didn’t think you were gonna bring that up. Do we have to go back to --
-- no be snore, and boom, pull the lever, you’re outta here. So, anyway, it takes more time to do endodontics, and you get less money. So, it takes you more time to make less money, when you’re doing a root canal. So, we just don’t want ethical issues to creep in, where maybe instead of having a guided consultation on what’s the patient’s best interest, we just don’t want people recommending treatment because maybe they don’t have the training, they don’t have the technology, and maybe they don’t have the desire to get a great result. So, there are specialists, and we can always think about a referral.
Okay. So, regarding the time involved, I think – like – okay. So, you have a root canal and then a crown. And pretty much when I had my root canals, I was pretty much back to normal in – within a month. So, you’re – I know that when you had your tooth extracted, that you had to – have the bone graft and then wait six months, get the implant, and now you’re still in the waiting period, before you get the restoration. So, that --
-- yeah. So, that’s a longer process. What if you had it right in the front, though, like if you – I mean, because I can’t see your missing teeth, because they’re in the back. But what if you had like – one of your front teeth needed an implant?
Well, obviously, if it’s in the aesthetic zone, the patients’ going to want the edentulous space covered up with a natural appearing tooth, realistically. So, that means you’re into wearing a flipper, some kind of a device that can come in and out of your mouth. It can replace one single tooth. So, there’s some cost and expense there, and they’re not exactly as comfortable, and probably you’re not as secure as a patient as just letting it go, if it’s in the posterior regions. You’re alluding to this, so, anyway, this is [inaudible] tangent.
But I went in 1976, and I had a root canal done by an endodontist in Boston. And then, within the next year, ’75, I had a second root canal done. Those two root canals lasted 45 years. They were exquisitely restored teeth. And in one week in Ruddle’s life, 45 years later, both teeth vertically fractured. So, you could say it’s bad luck, and, geez, the stars weren’t in alignment. I was thrilled to get 45 years out of those teeth. And so, anyway, it was, in my instance, desirable to have an implant, because I didn’t want the adjacent teeth prepped, and I didn’t want bridgework, and I wanted to just have it as non-invasive as possible.
And it also sounds like technology has come a long way, just in recent years. You were telling me about the – looking at the screen and adjusting it. So, it sounds like that wasn’t always a thing? Like, maybe people just did it by sight, at first?
I’ll divide it into thirds. The early years, say, ‘70s and ‘80s, people were lines of sight, and they were trying to line things up, and we had a lot of mal-aligned implants. In fact, in this town, it was normal to have Study Clubs and people talk about non-restorable implants, because they were placed so crazily. Well, then, we went to more advanced technologies. CBCT really showed us where the bone was. And then, sleeve guides became quite popular. So, an endodontist in town published work on sleeve guides, but that’s already old fashioned. I won’t mention names.
So, I went to Mark Bienstock. He said, ‘Oh, no, no. It's the X-Nav.’ Because they take the CBCT, they do oral imaging, they can register and [inaudible]. Then, he looked at the screen when he did my implant for X, Y, Z, and depth, because implants have been known to have been placed, even in our town, by specialists, in the neurovascular bundle. And that is really a serious event. So, technology’s really allowed implants to be placed quickly, efficiently, and very, very effectively. That probably gets us going towards prognosis.
Well, I just also wanna go a little bit – so, it sounds like that the patient is gonna choose what – probably what the doctor recommends or communicates is the best option. So, how – I mean, obviously the clinician needs to be able to communicate all of the possibilities or all of the options as objectively as possible. And is that kind of an issue? I mean, I don’t know. It just seems to me that I would feel that the person telling me what my options were might have, like, some subjective bias behind what they’re saying.
This is why oftentimes we give patients second opinions. And sometimes astute patients will ask for a second opinion, especially if they feel like they’re being guided in the consultation towards a preferred outcome. So, to play off of what you just said, it was really important, so I should say a little bit more. When somebody sees me or sees any dentist, the obligation is to communicate what it is you’re gonna do, the chair time, the cost, the prognosis, and anything else that you think could influence the result.
Two, you’re supposed to tell the patient all the options that are alternatives that are not about me. In other words, I’m not gonna be doing the implant or the bridge or the restoration, but it’s my job to tell them all the alternatives, chair time, the general cost of those procedures, risk versus benefits, and now they’re building knowledge. It’s their choice, not mine. And finally, the third thing is, we’re obligated to tell them what could happen if we do nothing. Those three things are what every patient needs to be told.
So, back to your ethical question, we shouldn’t have consultations that guide people into our preferred treatment, because it is much more financially remunerated to do an implant and put a casting on it than to sit down and do a root canal, for an hour to an hour and a-half. I said up to two hours. My whole career’s been in non-surgical re-treatment and surgical re-treatment. Re-treatment can take two visits, almost every time. So, if you’re gonna start spending that kinda time doing endodontics, you wanna really make sure you can bring the result in.
And let’s talk a little bit now, how the prognosis of a root canal compares to the prognosis of an implant. Is it about the same?
Well, I’ll get my readers on, and I have a few notes. And for the audience, we’ll make sure we drop these references in. But Ilan Rotstein et al., they did a great study. They looked at about 1 million – almost 1.5 million teeth, and what they showed is that at 8 years, 97 percent – 97 percent of 1.5 million teeth were still in the mouth. That was a huge study. That’s pretty amazing. That was based on insurance information.
Then, of course, we got a little bit down the road, and we got Iqbal and Kim, 2007, and they were just comparing single-unit restored implants versus single-unit restored endodontically treated teeth. And what they showed, at 6 years, they showed that the implant was 95 percent successful, endodontics was 94 percent successful. I don’t get too excited about four- or five-year results, because I now get recalls, 30, 35, or 40 years. So, it’s a nice start, I would say.
But I like the Petterson study, and he said that natural teeth, they exceed the life expectancy of implants, at 10 years. So, I would say that both procedures can have an amazing long-term result, but it’s like everything else in life. It’s proper case selection, and the procedures need to be properly performed.
If your implant is failing, what are your options, then? To get another implant?
Oh, we hadn’t rehearsed that one, had we?
[laughs] That’s a question that just came in.
You know, implants – we didn’t – we’re not getting into it, but when you do a root canal, that’s done properly, and when you have it restored properly, the records show, and data shows, and research shows that we don’t really keep seeing those patients, except for just annual check-ups, for the whole mouth. In implants, we get loose screws, we get broken fixtures, we get broken implants, we can have periimplantitis, we can have paresthesia, hyperesthesia, we can have drooling. We can have all kinds of things. And to be fair, lousy endodontics, we can have a lot of problems, blocks, ledges, transfurcations, broken instruments. So, back to properly performed, when endodontics is done right, it’s the cornerstone of restorative and reconstructive dentistry.
You had also said something about the criteria of what makes a root canal successful is different than the criteria of what makes an implant successful.
Ooh. That’s a really, really good question, because in implants, it hasn’t been a recognized discipline by the American Dental Association. There is the Academy of Osseointegration, and there’s other bodies and study clubs, but the point of having a specialty area is, you have residents. Residents generate research, and research over the years accumulates and becomes a body of science.
And so, survival is how implantologists count it. Survival means, it’s in your mouth. So, you can have crestal bone loss, you can have bone moving away, you can have bone loss on the lateral side of an implant, you can have drainage, you can have mobility. You can have – if it’s in the mouth, it's counted as it’s successful, but they say, ‘survival rate’. In endodontics, we have a much, much steeper [laughs] criteria, and I wish we could just go by survival rates, because we’ve all seen patients that come in to see us that had endodontics, and they have a big lesion, and they’re fine. They can chew equally well, left to right, you know, no hot or cold. They’re perfect. They’re not perfect, if you look at the radiographic criterion.
And our discipline does, and we say that that’s a lingering problem or a frank lesion. So, different criterias make it even harder to compare head to head, because our criterion of success statistics I gave you are based on bone regeneration, the patient’s asymptomatic, no sinus tracts, chew equally well left to right, no periodontal disease. So, pretty strict criteria.
Okay. And then, the last thing I just wanted to touch on is, it seems like there – there’s no – there’s not an implantologist? I mean, it seems like a periodontist can place an implant, an endodontist can, an oral surgeon can. So, how do you know who you should get your implant from?
You know, really, to go – to know who to go anywhere, if you need a root canal, and you’re new in town, call four periodontists, and see who they would refer to, if they needed a root canal themselves. Usually you’ll get a list of three names, and if you see one name on the list every time, that’s probably the first to go to. You can do the same thing with an implantologist. You can find one, because so many different people, to your point, actually place them. So, you want to go to somebody, I believe, that places them routinely. This is something they do all the time. And periodontists and some oral surgeons fall into that category.
I normally wouldn’t have gone to an oral surgeon, but when I checked around, Mark Bienstock, you were always on the top of everybody’s list. So, I was compelled to see you, even though I was thinking, maybe Shanelec, before he passed away, or I was thinking, you know, one of the well-trained periodontists in town, because they do ‘em quite a bit. You know, what ever happened to routine tonsillectomies? What ever happened to appendectomies? What ever happened to hemi-sections? Root amputations? We don’t [laughs] do ‘em anymore. Periodontists do implants.
Okay. All right. Well, that’s a lot of information. Thank you.
Thank you. And remember, we’re not experts. I’m not the expert on implantology. But don’t look at it as endo versus implants. Look at it not either or, look at it as and both. Look for possibilities.
The one that’s best for the situation.
The one that’s best for the situation.
So, that’s our show for today. We’d like to leave you with some show bloopers and some behind-the-scenes footage. Hopefully you’ll find it funny . Some of you might crack a smile. Some of you might be on the floor rolling and laughing. We’ll see. [Background music playing] [Bloopers video] [Music playing]
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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.