Clinician Influence & Fractures Swaying Treatment & Radicular Root Fractures

"Whose Job Is It?" starts off the last show of Season 10…Specifically, whose job is it to clean the office? Then, a Tough Question: To what extent does a clinician try to sway treatment a certain way? After that, Ruddle is at the board showing how to manage radicular root fractures. The season concludes with some family time; see a little video of the Ruddle family’s trip to Maui this past summer. Hopefully this will inspire you to create some fabulous family memories this holiday season!!!

Show Content & Timecodes

00:41 - INTRO: Whose Job Is It? – Office Cleaning
06:37 - SEGMENT 1: Tough Questions – To What Extent Does a Clinician Try to Sway Treatment?
24:44 - SEGMENT 2: Managing Radicular Root Fractures
42:40 - CLOSE: Maui Family Trip Video

Extra content referenced within show:

  • No additional references to note!

  • Other ‘Ruddle Show’ episodes referenced within show:

  • The Ruddle Show, S04 E01 – “Tough Questions & SINE Tips: Who Pays for Treatment if it Fails and Access Refinement”
  • The Ruddle Show, S04 E07 – “Tough Questions & Choices: The Appropriate Canal Shape & Treatment Options”
  • The Ruddle Show, S09 E04 – “Controversies & Iatrogenic Events: Sharing Knowledge Pros/Cons & Type II Transportations”
  • The Ruddle Show, S10 E01 – “Delving Deeper: Progressive Tapers & DSO Troubles”
  • The Ruddle Show, S10 E06 – INTRO “Dangers of DIY Teeth Whitening” within “Vital Pulp Therapy: Regenerative Endodontics in Adolescents”
  • The Ruddle Show, S10 E06 – “Vital Pulp Therapy: Regenerative Endodontics in Adolescents”
  • The Ruddle Show, S10 E03 – “Advanced Endodontic Diagnosis: Endodontic Radiolucency or Serious Pathology?”
  • The Ruddle Show, S10 E01 – INTRO “Welcome Back/Update” within “Delving Deeper: Progressive Tapers & DSO Troubles”
  • Downloadable PDFs & Related Materials

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    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...

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



    …So I’m thinking this is probably the job of the newest hire. Just kidding.


    The rookie!...

    INTRO: Whose Job Is It? – Office Cleaning


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


    How you doing today?


    Pretty good; how about you?


    I’m really happy, and it just was told to me by you that this is Season10, Show 8, Show 90 altogether from the very beginning. So hope you like the show; Show 90.


    And this is our last show of this season.


    Oh no, where’s the handkerchief? I feel a little tear coming.


    Okay. Well thought we would start our show off today with a little mini segment of Whose Job is It? So probably everyone in your office has specific assigned duties. But whose job is it to clean the office? Well it’s likely that you have an outside cleaning company that comes in periodically to do the big cleaning. But I’m more talking about who’s in charge of the daily spiffing up of the office. Like spot vacuuming, wiping down surfaces, maybe doing some toilet checks, taking out the garbage, that kind of thing. So I’m thinking this is probably the job of the newest hire. Just kidding.


    The rookie!


    So there are some different strategies you could take. You could say everyone’s in charge of keeping the office clean, so if you see something that needs to be done, just do it. Or you could also assign specific duties on rotation. So what strategy do you prefer?


    Well everything you just said. When people are hired, once you make the right decision and they made the right decision and we’re going to come together, they’re given a complete list of their duties. And you would expect if you’re an assistant, you’re going to get all that; receptionist would be different. But basically beyond assisting, there are things that need to be done on a regular, daily basis. You would expect there’s maintenance people that are involved in maintenance, technology. There’s the common areas, reception area; there’s the more private areas, you mentioned bathrooms. So those are all assigned and people do them, and there’s a rhythm and a rotation.

    But what you’re talking about is the key, and that’s to basically spiff up the office during a dynamic day of patient practice, so things happen. And your best clean carpet can end up have a 2x2 gauze, or a cotton roll, or a Kleenex from a patient that dropped out their pocket. So basically the philosophy of the office is see something, do something.


    Well, we tried these various strategies in my own home. We’ve tried if you see something, do it; and I find that I’m really the only one who sees it, so that’s a problem. Then we tried to assign duties.


    Oh that’s interesting. They don’t even see it.


    Then you get the situation where if you assign duties, maybe someone that is in charge of something is too busy to do it and it doesn’t get done. And then you might ask someone else; well why are the dishes still here? And I hear, “I don’t know; it’s not my job.” So the things you just don’t want to hear and you don’t want to hear like, “Well it doesn’t look messy to me.” You don’t want to hear that. You don’t want to hear, “It’s not my job.” You don’t want to hear, “How come so-and-so never does anything? It seems like I have to do all the chores.” So you don’t want that either. So I guess you just really kind of need a balance of assigning chores, but then also picking up the slack and helping out if someone’s busy and can’t do their chore maybe help them out.


    I’ll have to change my approach. It can’t be see something, do something. You said they don’t see it. If I walk down the hallway, I don’t see the cotton pellets and the cotton rolls on the floor, so maybe we’ve got to say look for something, see something, and do something.


    Yes. Why don’t you give us some words of wisdom on how to solve this conundrum.


    Well I think beyond assigned duties – that’s the whole thing – is look, see and do. And so be a helper. I don’t want staff coming to me and saying the carpet could be spiffed up, that’s Mary’s job; that doesn’t help me at all. See something, do something; the job is bigger than all of us. And the other person might have done a great job, but if something happened – again the dynamics of that day.

    So see the office through the patient’s eyes. That means you have to look around if you can; not just walk back to the operatory – looks fine, I see nothing. So you’ve got to really make sure that you are coming from the context that you’re sitting in the reception room; what do they see? You’re taken back behind; what do you see in the hallway? What do you see when you glance into rooms? What do you see when you’re seated? Did you see the cobweb up on the ceiling and nobody saw it? We live there, but they don’t live there, so they’re watching. So look at it from the eyes of the patient.

    And then finally, leaders -- dentistoes have to be the leaders. So it all starts with you. You can’t just be like I stepped over three cotton rolls; would you get it for me? No! You get the cotton rolls and lead by example.


    You know I have to say, I went to our audience so everyone I’ve ever met in the whole world. You do the most cleaning of everyone, and you do it the most thoroughly. So this was intimidating to me as a child, to live with your cleaning standards. But as I’ve gotten older, I’ve actually found that I’ve sort of turned into you with regard to cleaning. Now I have that kind of frame of mind where I just want things clean.

    I do want to apologize to Isaac in case I offended him – that’s my son – because lately, he has actually really started helping out a lot around the house. It’s not unusual for me to walk into a room thinking I was going to have to do a chore and find out that it’s already been done. So a shout out to you Isaac; thank you very much!


    Yeah, thanks Isaac for rotating the tires, changing the oil, and making sure that the gas is full.


    So just so summarize whose job is it to the office cleaning; it’s everyone’s job.

    All right. Well let’s get going on our last show of Season 10.


    All right.

    SEGMENT 1: Tough Questions – To What Extent Does a Clinician Try to Sway Treatment?


    Okay, so today we have another Tough Questions segment. And in case you didn’t see the last one, it’s where we explore a certain question that maybe doesn’t seem to have a clearcut answer right off the bat. But our hope is that after some discussion, you’ll at least have a better of where you stand on the issue.

    Alternatively we might ask the question that maybe might appear to have a very obvious answer. But when we talk more about it, maybe the answer is a little bit more complex than at first thought.

    So some examples of some Tough Questions segments we’ve done on our show are who pays for treatment if it fails, what is the appropriate canal shape, and should endodontics teach GP? So if you’re interested in those discussions, check back on some of our past shows.

    All right. Well our touch question for today is – can I get a drum roll – to what extent does a clinician try to sway treatment a certain way? Now the easy answer is that the doctor recommends what’s best for the patient. But maybe it’s a little more nuanced than this. So let’s start by methodically looking at the factors that would influence treatment decisions.

    So to start, a patient comes into your office, you diagnose the problem, and then you thoroughly explain it and present the various reasonable treatment options?


    Yeah, that’s exactly how it goes. And just to put this aside, we’re not talking about the zebra. In other words they come into the office and you can’t figure out what it is. But we’re assuming, like Lisette said, that there is a firm diagnosis. And once you have the diagnosis, you need to give them the various treatment options. And there’s oftentimes three or four different ways you could go.

    As an example, I’m an endodontist, so they were presumably sent in for endodontics; root canal treatment. So I can do a root canal. I can have the tooth extracted and refer them to their general dentist for a bridge. You might want to avoid cutting down adjacent teeth. They might even be heavily restored, future problems, so you might extract it and do an implant. You might extract a tooth and do nothing, and you have to tell them what might happen if you leave a space and drifting and things. And you might just talk about a flipper; something that goes in and out.

    So all these have to be explained, all of the pros and cons of both, the cost and time associated with all these various options. And then I usually turn to a patient, and I’ve written this all down and I’m drawing pictures and I’m writing the fees in, and I’m communicating what I think could be successful. I always say do you have any questions? This is complicated and this is my world, not yours; but it is your tooth so you’re here. What can I do to explain this a little better? And they usually say they know, they understand.

    And then I go how would you like me to schedule, because I’ve laid out several things. And they usually will say let’s save the tooth. So that’s how that works.


    Okay, well I imagine that finances, like the patient’s financial situation might also determine what treatment option they would choose. I know that about a third of Americans don’t have dental insurance, so I would think that sometimes people might have to choose a treatment option that maybe isn’t their first choice just for financial reasons.


    Yeah, if patients are a little hesitant to proceed, and you’re sitting there and there’s usually three people; you and the patient and I’m sitting and they’re sitting and we’re looking eye to eye, and we’re trying to be kind. We’re laying it out I think in a very benevolent way; there’s no thumb on the scale. It could be finances, but it also could be they can’t lean back in the chair; I’ve had that happen plenty of times over the years. Not in a week or a month, but it happens enough that it’s like a consideration. What if they say they gag; they can’t have anything in their mouth? Even a periapical film makes them go into crazy gagging. What if they’re working and they have a job and they can’t get off work and they have considerations and they have to work that out in their mind or with their job? They could be on medications for cancer or Paget’s Disease, and maybe you can’t do an extraction, or maybe you can’t flap the case and do surgery. So all these things have to be discussed.

    But at the end of the day, you might want to ask a question. I always come from if you must speak, ask a question, because I’m trying to get in the patient’s head and if we’re just sitting there like bumps on a log, it’s not a two-way conversation. So I usually include people constantly when I’m talking and ask questions. I want to know that they're coming along for the ride. So you might ask these questions to identify what the problem is, and it could be about money. And if it is about money, then you can remind them – and I’ll say this kindly – look; you’re in pain today, poverty is temporary, let’s get you comfortable. We can at least do that. And then you’ll have more time to think about what’s best for you. But palliative treatment could be a Beth Damas pulpotomy. We’re calling it now something that was it before, but now that the show has been launched and she’s given her fine lecture, a pulpotomy – I did it a lot on emergency visits and patients could hold a lot of times for several weeks. Of course it depends on what the pathology was.

    So anyway, you could do a pulpotomy and dismiss them. You could have them get another opinion if that would help them. But you could work something out. Sometimes I’ve done extended payments or done it free or whatever. Because overflow does come people’s way; you have to believe in miracles.


    Yeah, I really liked what you were just saying about really trying to find out where the patient’s coming from. Because there might be certain issues that are maybe holding them back from signing up for a certain treatment, but you don’t know what they are. Like you said, they might be afraid, they might have financial issues.


    I missed that one; fear.


    Well I think you might have said – or maybe you didn’t; maybe you were talking about time – but you don’t really know what is holding them back. So I think it’s really important to communicate with them. Maybe ask a question, but then ask more questions. Because sometimes people just don’t immediately open up and say what they really think, so you might need to ask a few questions to get them to open up.

    So right up to this point, it sounds pretty good. You are talking with the patient, explaining to them the options. You’re maybe giving some suggestions or recommendations and talking about finances. So would there ever be a situation where you would really be pushing for them to choose a certain treatment?


    Well yes. I’ll go to the bizarre, because we’re thinking of just daily grind of dentistry that’s pretty generic; we see all kinds of things. But we don’t necessary see a cancer every day or a squamous cell or an ameloblastoma. And if we listen to David Landwehr’s previous show, there can be some pretty serious pathological potential. So if I see somebody that has a potential pathological problem that it’s like kind of crazy – I’ve not seen it very often or maybe never – we’re going to get that patient to a maxillofacial oral surgeon post haste.

    And without scaring them, but then you have to create enough urgency. I want to write this down in the chart, and I want the patient to know that I’m going to communicate this to their general dentist. Because again, get more people involved so you can give the patient their best possible shot at it. So there’s a time to be aggressive, and that’s not pick-pocketing them, it’s not taking advantage of them, it’s in their best interests.

    And then the other one is there could be some issues with their medical. I think I mentioned some of this already, but what if they can’t open; what if they have a TMJ problem? What if they can’t lean back; what if they’re a gagger? I mentioned all of this. What if they’re claustrophobic and you’re going to have to put a rubber dam on?

    So those are things that might influence dental treatment, but I’ve been able – across all my decades of practice, I can pretty much work with all that. Those were hardships; you wished your fee was twice as much sometimes to be honest. But you can get that patient through it. Mainly I get aggressive on things that are life threatening.


    All right. So everything we’ve talked about so far regarding factors that could influence treatment decisions are you communicating objectively and neutrally – like being neutral if possible – what the various choices are. And then also maybe giving a recommendation of what you would do if it was your own family member. And also paying special attention to the patient’s specific circumstances. So this all sounds great so far; sounds very straightforward.


    Do you have a couple of concerns?


    I’m wondering if not all treatment recommendations come from such a noble place. Like what if this clinician’s treatment recommendations are, either consciously or unconsciously, more self-interested? An example scenario might be this. So say the tooth is a good candidate for either a root canal or an implant. Now your office doesn’t do root canals, so you would have to refer it out. But you do place implants, so you’re really pushing towards the implant because you want to keep it in office and maybe you need the income. So is this something that might ever happen?


    That’s never happened once; not even one time. We are as clean as the driven snow as a profession and that has never happened. No, that happens all the time. And when I was younger it used to drive me crazy, and now I try to stay in my lane. But to play off you a little bit; I’m going to be tough on you out there today, and I’m going to be tougher on the young ones and a little kinder and cut more slack for the older ones.

    What does it mean to be a young dentist? It means you just got out of school and you’ve got a lot of debt. It means you thought when you watched your dad or somebody you really admired practice, you thought you’d have your own practice, but here you are working in a big DSO and you’re cranking it out every day. And not all DSOs are the same. Some are very, very good – we’ve talked about that – you could get a Gladstone model maybe. But there are plenty that you wouldn’t want to go to yourself.

    So they might have a young practice and they’re working hard as an associate, there’s a cash flow problem. They don’t have a lot of cash coming in. And another problem is they’re not experienced in business. So they’re looking at all of this, but there’s a little quiet conversation, or maybe not even a recognizable conversation, that I’ve got to pay the bills this month. There’s lifestyle problems; I didn’t even mention that. Why do you go out as a young dentist and you have to buy a new car and a new house, a new this, a new plane? You put yourself in enormous stress. When I was young – and it’s good not to be young anymore – but younger dentists worked nobly under the tutelage of an experienced person. And they came along slow; they could be slow and methodical, get their efficiency up, the speed’s coming, and you crawl/walk/run. But a lot of times they go out and try to do something on their own, the lifestyle. How about divorces? Divorces just kill cash flow. So all of these do influence the choices that you give patients to make.

    And to you point – do you want me to go off on it a little bit right now, my biggest gripe? My biggest gripe is a tooth that needs a root canal, virgin, and it’s extracted because the implant is more predictable. That person is ill informed, they're unethical, and they really need to have a wake-up call because this is a bad way to practice. And this isn’t going to happen to more mature practitioners. It usually happens to younger people in their first 10 years of practice.

    So the worst one is – that’s bad – the worst one is it was previously treated. Let’s just say for fun, it was filled endodontically short and it’s got lesions on all the roots, multi-rooted tooth. You extract the tooth because it’s failing; it’s got infection and you’re going to put in an implant and save the day. That’s not coming from what’s best for the patient. That’s coming from what’s best for the doctor.


    Okay. I assume that maybe doctors would also – maybe they might want to recommend a treatment because they want to use the technology that’s in their office. Like we talked about before; recommending a CBCT for every patient because you’re trying to recoup on the cost of your CBCT. Maybe they don’t need it. So technology might -


    If you have a microscope, you might do a root canal. If you had X-Nav you might do the implant.


    Right. And then I imagine that experience could determine treatment. Like you need to be informed of all the options as the clinician. You need to be informed about all options that can be successful. And not go you know what? Vital pulp therapy doesn’t work. I tried it a few times and I have not had success; so I’m not going to recommend that because it doesn’t work for you.


    You brought up a good point. A lot of clinicians practice based on their experience. Now experience is important, but if you’ve had bad experiences with vital pulp therapy, how come so many people have great experiences? How come thousands, hundreds of thousands of teeth are saved through pulpotomies and pulp caps. I mean get serious. I’m an endodontist; you’re supposed to be taking all the pulp out. But let’s be honest. Many, many patients have benefited from these procedures that aren’t as aggressive, and they work quite well when the diagnosis is right.

    So you’ve mentioned training; lack of training pushes you away from something that maybe is best for the patient because you aren’t trained up very well. And then bad experiences. People hear things over the fence, they talk to neighbors, they’re at work, they hear it in the locker room, they’re getting a cup of coffee with a pal, they always hear stuff. And people get influenced by those things.


    Okay. Well I imagine that there’s probably what’s currently trending could also influence treatment decisions. Like 15 years ago implants were very popular and being recommend a lot; then now we find out that there’s a lot of periimplantitis that’s popped in, so maybe they’re not as recommended as they once were. Maybe 30 or 40 years ago orthodontists’ recommendations were more aggressive than maybe they are today. Could what’s currently trending influence?


    Oh yeah. I’ll talk about three things real quick, and they’ll be just one lens. We’ve talked about endo versus the implant. I just kind of went off on that. We’ll have to do a podcast on it, because I could show a lot of fascinating stuff that would make your hair stand up and collapse. So implants versus endo. Training, experience, technology, we mentioned that. Financial overlays.

    How about ortho? Ortho has the same thing. Ortho, about twice as many cases are done today annually than were done 30 years ago; twice as many. But they have controversies. One of the legacy treatments was 4-by extraction; by, by, by, by – and bye-bye and they’re out. Well then that caused other issues. And so there’s always – in any profession, there’s turf battles, implants versus endo, 4-by’s versus no 4-by’s.

    Home teeth bleaching, we’ve talked a lot about that. Go home and do it yourself; here’s a kit. Go to the – what kind of store is it? Some kind of store you go, a drug store, and you can pick up these over the counter things. But what if you love to do laminates and you’re getting around $5000 a laminate; your $2500 to laminate. And they need brightening from 6-11; canine to canine. Maybe your motivations are a little wrong; maybe you want to put laminates and cut all those teeth down versus doing bleaching.

    So every discipline has their controversies, and ethical dentists give the patient every single choice; starting from what they would probably do in their own mouth, because that’s a good place to start.


    Okay, so it looks like there’s a lot of different factors that could influence treatment decisions. There’s the patient consideration, and then there may be clinician considerations which we were just talking about, and also maybe what’s currently trending. But it seems here that the most important thing is the patient consideration; that you should really be patient focused. And if you’re a clinician trying to sway treatment, maybe even unknowingly, but maybe now that we’re discussing this, you might go hmm; I wonder if I’m doing that a little bit unconsciously? Well then maybe stop doing that.


    Or get trained up so you can offer a bigger range of treatment options to your patients. I think in closing, about the only thing I want to say is you’re in continuous training. G.V. Black, the Father of Modern Dentistry in America, said that no student has any right other than to be a professional student for life. Okay? For life. So if you are finding that you’re going towards implants, maybe train up in endodontics. Because endodontics – if you have a pendulum, it keeps always swinging. We were talking when we were going through the script the other day, and the pendulum gets way out here and everything looks like an implant. And then all of a sudden wow; there’s bone recession. Oh, the implant’s got mobility. Oh, there’s infection. Oh, periimplantitis! Oh, save everything! You go out on a limb. Four broken instruments, five mal-aligned posts; we’re going to go in there and save it because we can. Make yourself the patient and you’ll have the answer.


    All right, thank you.


    Thank you.

    SEGMENT 2: Managing Radicular Root Fractures


    Welcome to another episode at The Board. We’re kind of in that Halloween, American Halloween season, and as it approaches as I do my daily walks, I notice there’s a lot of decorations in the neighborhoods. Kind of spooky, ghoulish-type things. That’s why I’m showing you this, right? No. What we’re doing today is you’re practicing alone, your schedule is intact, everything is going perfectly. And you know what? The phone rings and somebody has been hit. And trauma can come in a lot of different varieties – I won’t explain them all; you’ve seen them, you know about them. But they can mean immediate upset in somebody’s life, and something has to be done usually right away. So it’s an intrusion into an otherwise busy scheduled day, and of course the first thing you want to know is are you able, capable and prepared to meet the challenge?

    So if you look at this one, we’ve got to remember this has been a traumatic accident. This is face going into the steering wheel of a car. It’s an adult patient, so this isn’t – you know Beth was talking to us. Dr. Beth Damas was talking to us about children and with teeth that are immature in their development. This is a mature patient.

    So we don’t have a great blood supply. And we‘ve got to remember; when trauma comes in, we have to be sure we check other teeth. Because the blow might apparently hit one or two teeth, and you’re all focused on those two teeth and the lacerations, the puffy lips and all that. But remember, blows come in and dissipate out over several teeth, so the whole point is to be sure on your follow-ups you’re looking ahead at adjacent teeth as well. Because they can undergo pathologies, resorptions, internal, external, etcetera.

    You’ll notice right now before going further that we have a tooth that has been subluxated and it’s down perhaps as much as about 2mm. So we have about a 2mm supra eruption if you will from the trauma, and some other mal alignments, so what are you going to do?

    So let’s marry this up with the film, so you kind of know what we’re looking at. So when you look at the film, you can see in here that you’ve got about that same 2mm area here that is going to bother the patient just closing their teeth. So one of the things you do is palliative treatment – address wounds and soft tissue things, suturing if necessary – but mainly get the teeth back into alignment as fast as possible.

    So you’re looking at this film and you’re going my goodness. That’s a serious fracture; what are you even thinking about Ruddle? Because I have practiced long enough that I know that in spite of dentistry and Cliff Ruddle and all of the great things we can do as professionals, sometimes things get better in spite of us. Sometimes the better part of valor, better judgment would be do nothing and observe. So my job was to push this tooth back up and seat it, so a little bit of anesthetic. But you can notice we have some pieces in here, fragmentation, you can see other pieces in here. There’s something kind of in here.

    So we’ve got those three pieces, and in the trauma visit you don’t talk about treatment planning – we’ll talk about that in just a little bit. But you could talk about root intrusion, try to bring that root down, but it’s probably too short. Anyway, you could bring this root down, but you would only have about this much to work with. So that’s probably not going to fly for the patient.

    So all I did is push the tooth up about 2mm. You can see this little area here and you can see it’s pretty closely approximated over here. And same thing over here; you can see there’s quite a gap in here and we’ve got a little bit better approximation. So it’s up about 2mm; we’ve got the insides, the ledge is lined up. And I have an orthodontist in my building and right off to ortho; because I wanted to tie this tooth in and I wanted to share responsibilities. There’s that old expression, “If more than one person is responsible for a miscalculation, no one’s at fault.” So get a lot of people involved, because you’ll also learn from them and they’ll tell you what they can do.

    So off to ortho for a while. And the patient – I followed up a couple of times by phone, our office did – but basically, the general dentist and the orthodontist were watching him. And then the patient wanted to come back in, and the orthodontist and the general dentist referred him back to me in about one year to see what I thought and should we go ahead with treatment?

    So at one year we got the ortho band off. We went to kind of a soft splint in here. I placed that; I can place it and just kind of wrap it on the lingual a little bit. The tooth still wiggles, but it restricts its total range of motion. So if you can keep the mobility about in the range of a healthy tooth, it’s not fractured.

    So you can see when I looked at this; I’m not going to file under this. I did my vital pulp testing. It was non-vital, so you could have argued to race in immediately. But with all this amputation and severing of vasculature I didn’t really think it should be vital. But it’s not getting discolored. I don’t see any resorptions laterally or internally, and I just see improvement. I see callous formation between the fragments.

    And then finally if you saw the patient five years after that – so this is about one year and then here we are at about five years, and you can see it even looks better. So as we go across the board you can see better, better, best! And I can tell you right here, we knocked off the little inter proximal splint, the mobility isn’t any different than the adjacent tooth, the patient is comfortable, you can palpate. So do nothing is what we did with this radicular fracture.

    So you don’t always have to be a hero and jump in there and try to throw the kitchen sink at it. Sometimes just step back and then have other people help, and then kind of reevaluate and keep following carefully; carefully follow, carefully follow.

    All right. So we’ve got to get this cleaned up and go on. So let’s get going and look at the fractures. So you look at this tooth. You can probably imagine there was trauma years earlier. I think you can see the reverse apical architecture. I think you can see the tooth’s been opened, and there’s a massive lesion in here. And this tooth, it hurts. It’s not overly mobile, but it’s kind of weird. When I wiggle the tooth, I can see the tissue you up in the vestibule kind of flexing like there might be mobility between parts; this is what I was thinking. So I don’t think I can do much better endodontically on this tooth. This tooth I’m not going to be able to get the classic capture zone, so where we can pack into a narrowing cross-section of diameters; have a capture zone up in here that can pool the irrigant, we can pack warm gutta-percha and out with the anatomy.

    So I don’t want to waste a lot of time trying to prepare this. I’m going to do a quick root canal on this and go ahead and clean this all up, and maybe there’s a fragment. So that’s what I’m thinking.

    So guess what? You go ahead and you lift up the flap. And see this used to be going on up like this; goes like that. This was more like, you know, like this with that reversed architecture. So I’ve already cut this off; I have resected pretty much this just to see what’s going on, and that’s why the roots aren’t way up here at the top of the lesion which you can see on the radiograph. Well, it’s pretty interesting. A piece did come out. It was a long piece, it was an oblique fracture, apical coronal. I’m going to show one pretty soon, coronal apical; just backwards.

    So this is a big root end. You can see how this big old piece of cone – this is a gutta-percha cone – was butted right up against that. You know, Beth Damas would be very happy, because this endodontist got root formation. So they packed it to where they could control it, and the root – she packed. She did what Beth told us many shows ago and it actually formed. It was just the trauma that undid everything.

    So that’s kind of interesting to notice that root end, that big block of apical dentin. And then if you start to see where this ting plays out, the fracture plays out way down in here. So we have done the warm gutta-percha technique – clean, shape and packed that. I wasn’t so careful apically because I’m going to cut it off and reverse cork it. And then this just got beveled down until I can see tooth structure; until I can see tooth structure all the way around and it can hold my obturation material that’s corking the end of a very, very big system.

    Well you’re thinking the crown/root ratio is not so good. You’re thinking how do teeth like this even make it? Yeah, you can talk about an implant, but not so much on this patient. And besides, this is an osteogeneration procedure so we’ll have better bone for an implant if we need it. Let’s go forward and see what happens.

    So slide it over and there’s our recall. Everything’s cleaned out; massive lesion. And these things are pretty big sometimes, so you’ve got whisper in the operatory so there’s no echo.

    And then let’s see what happens over time. And you can see marvelous healing; got a PDL on that lateral incisor. And the bones just come in nicely, a little scar tissue up against that retro material. But you know, teeth that are anterior don’t get a lot of loads, and so oftentimes patients, if they just want to be a little bit careful like they might be with veneers or laminates, then they can get away with a short tooth.

    Okay? So we’ve looked at a couple of fractures. One, do nothing; one, just go ahead and clean it out and see what you’re able to have left. And then we’ll look at one that happened the other way. So again, we have a lot of trauma don’t we? And so patients that play sports should be wearing mouth guards. And you slide these over and you start to see; there is the problem.

    So the patient says the crown is loose, so you take the crown off with a little bit of effort, minimal effort. A little bit of anesthesia because the crown has a post and the post is attached to a segment that’s moving. So that segment is moving. So we have to lay a flap and get up in there and see, well where is that coronal apical fracture? Just showed one that was apical coronal, so where does this one play out? How far does it go up the root? So you have to lay a little flap and go in here and look. And you can start to see with an elevator; this piece is coming off; you can see it very nicely in here. And you can just take that out and start seeing where the margin might be for the restorative dentist.

    So I think you can see right here that we have light hitting an edge, but we kind of have a scalloped edge coming around. So this fracture is all in through here. We’re pushing a silver point out. That silver point was hard to get out; it’s pretty big. The canal is not tapered, so it’s pretty much a parallel silver point in a parallel shaped canal. So there’s a lot of contact over a lot of distance, so the resistance is quite remarkable, but we could manipulate it and finally get it to come out. And with having it come out, we just go ahead and do a clean, shape and pack. And put the post in, because I’m anticipating if we had a post, we probably need another post. I don’t like posts like this. I think posts should basically – if this is our bone and this is our root, we should try to get to about mid-root. That would be several more millimeters, and if we did that, it would have carried the load that came in that broke the tooth. It might have broke the tooth anyway, but it would have carried a deeper sub crestal. And posts that are too shallow set up fracture lines; they set up fracture potential.

    So here’s the new post, and like a Christmas tree head this is a V-lock post; it’s cemented in. You can see up here we have beveled off the roots; you can see the roots beveled all the way around nicely; you can see pink gutta-percha. I didn’t put a retrograde in this time, because Ruddle did the clean, shape and pack. And how does it look? How does it look? So it comes in like this, that’s how it looks post-surgery, and this is how it looks many years later. So that’s just another kind of a fracture.

    So loading fractures, we need to be able to react, know what to do, call in another colleague if we need help. Because these things are good services for patients because it’s maintaining; it’s retaining their natural teeth.

    One last case and we’re out of here. So we have different fractures; you’ve seen trauma fractures, you’ve seen occlusal load fractures and those are typically crown down. So I’m going to show this case at another time. This is Cliff Ruddle. I was talking to the shooter, my grandson, this morning and we decided this would probably be a podcast so we can talk about it in detail. Nothing will be held back.

    Anyway, it looks pretty good doesn’t it? That’s 41 years after a really good friend of mine did it in Boston. Well, it got sore. The radiographs look fine 41 years later. Notice the intact PDLs; notice there’s a different angle. This is straight on, breaking the contacts. Notice when we come off angle; we start to separate, there’s two canals in there. But that’s how it looks. So Dr. Terry Pannkuk made the diagnosis, a Santa Barbara endodontist, my pal and clinician extraordinaire. And so basically off to get an implant. And Dr. Cherilyn Sheets is doing all the other efforts, the oral surgeon in Santa Barbara. Dr. Bienstock, he put in the fixtures. So I’ve got to give credit to all these people. It’s just a marvel to go to somebody else’s office and see what they’re doing and how they’re talking. Using X-Nav and 3D guidance systems and notice the threads.

    So the big fear of course in implants is what happens when the bone recedes to the first thread, and the first thread is the kiss of death. So we’ve got to keep that collar of bone Ruddle; got to keep it another 41 years, you know.

    Well, then there’s loading fractures, okay; so that was a loading fracture from fracturing a tooth. I might have shown this case a long time ago, but not in its entirety; so here we go real quick. But this was done by an endodontist. You might say it looks a little weak in here. There’s a lesion of endodontic origin; the shapes are pretty full; there’s something maybe in here, I don’t know, but the patient hurts to percussion. And if you take and pull back a flap; it did not probe. The sulcus was intact. And you can see the fracture starts to play out; it plays out. And so I’m probing up here, and I’m probably probing down to here, probing down to here. I have not lost attachment there, but it’s a more overt fracture. So I’m showing you loading fractures, but this is a dental loading fracture from obturation. So we have loads that come down, like you get a rivet in a kitchen, in a restaurant, that’s in your food. Maybe you bite on a piece of ice or something. But also when we’re packing or doing lateral condensation and wedging pluggers in there, we can get loading fractures.

    So in the old days, you know, implants weren’t as perfected. So you know what? It’s a hemi section. And I’ve talked about this before. Leave most of the bulk; if I go back one slide – and I won’t – but leave the bulk on the abutment. Now you’re going to have a bridge; you’re going to have a little 3-unit bridge in here. You leave this guy alone, and you leave this guy alone. So it’s a 3-unit bridge; it’s a shorter 3-unit bridge than you’re usually accustomed to.

    That’s 30 days later and the tissue looks terrific. This old gutta-percha is in here; that tooth needs to be non-surgically retreated; retreatment, that’s what we’re going to do. And we go back in and work the end, and things that don’t look right usually aren’t right. Notice how there’s nothing going to this lesion; no filling material extending; it probably wasn’t cleaned or shaped. And in any event it was biffed. And anatomy rules. And to the extent we get the anatomy, endodontics tends to work quite well.

    So I think in closing, you’ve seen some fractures of different kinds, trauma fractures, loading fractures, radicular crown up fractures. And I guess it reminded me of David Landwehr, who said some shows ago, you’ll recall. He said anything can happen to anybody at any time, and that’s kind of how trauma occurs.

    CLOSE: Maui Family Trip Video


    Okay, we did it! We finished Season 10! High five!


    Well that was fabulous. For you out there in the audience – and there’s 10s of thousands of you now that happened over the years – it’s been such a great pleasure working with Lisette, Isaac the Shooter – my grandson, and Lori the producer. And then Phyllis is always managing everybody. So we’ve learned a lot doing this, and we hope you’ve learned a lot. And yeah, we had a pretty good season and I’m really excited about the seasons ahead.


    What are you going to be doing in the off season?


    Well I’m going to be doing what endodontists do. I’m going to be working on giving three lectures that I’ve never given in this exact manner. It will be shape/clean/pack, diagnosis and all that. It’ll be non-surgical retreatment. People say we have bricks; those four DVDs and we’ve seen them. This is going to go much deeper than that; like if you came to Santa Barbara and got baptized. And then finally, we’ll be doing surgery. And these will all be continuums and there’ll be hours of presentation and they’ll just be building. And when you have finished that, you will have gone through quite a curriculum.


    And we’ll be incorporating those into the PORTAL learning on our website, on our Ruddle Show website. And then we’ll be doing podcasts too.


    Yes, we’ve done I think three that we’ve released; those are just getting our feet wet. But we have our podcast curriculum lined up where we can really go quite broad into these topics that are of interest, and we can go deeper and there’ll be guests on where we can banter. I’ve been talking to Ben Johnson; he’s going to join us. So Ben, get your gun loaded!


    Okay. Well you probably have noticed or maybe wondered why we have a map of Hawaii behind us. Well that’s because at the beginning of the season we promised that we would show you, at some point, our footage from our trip to Maui this last summer. And so now we’re going to do it. Are you ready to watch it?


    Ready to relive last summer.


    Okay, well Happy Holidays to everyone. Hopefully our video will inspire you to create some of your own fabulous memories over the holidays. And we will see you next year in 2024 on The Ruddle Show, but we’ll see you before then on podcasts. So thanks for watching.


    Have a beautiful holiday.

    [Maui Trip Video]



    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

    Watch Season 11


    s11 e01

    Delving Deeper Again

    Financial Investing, the Tooth or Implant, Accessing & Flashing Back


    s11 e02

    Artificial Intelligence & Disassembly

    Differentiating Between AI Systems & Paste Removal


    s11 e03

    The ProTaper Ultimate Slider

    Special Guest Presentation by Dr. Reid Pullen


    The Ruddle Show

    Commercial Trailer S11

    Watch Season 10


    s10 e01

    Delving Deeper

    Progressive Tapers & DSO Troubles


    s10 e02

    The Dark Side & Internal Resorption

    The Resilon Disaster & Managing Internal Resorptions


    s10 e03

    Advanced Endodontic Diagnosis

    Endodontic Radiolucency or Serious Pathology?


    s10 e04

    Endo History & the MB2

    1948 Endo Article & Finding the MB2


    s10 e05

    Collaborations & Greatness

    Crown Removal vs. Working Through & Thermal Burns Q&A


    s10 e06

    Vital Pulp Therapy

    Regenerative Endodontics in Adolescents


    s10 e07

    Endodontic Surgery & Innovation

    Surgery Photo Review & Exciting New Technology


    s10 e08

    Clinician Influence & Fractures

    Swaying Treatment & Radicular Root Fractures


    The Ruddle Show

    Commercial Trailer S10

    Watch Season 9


    s09 e01

    Moving with the Cheese & Delving Deeper

    A Better Understanding of Change & File Brushing


    s09 e02

    The Dark Side & Post Removal

    Industry Payments to Academics & Removing a Screw Post


    s09 e03

    3D Tomosynthesis

    Special Guest Presentation by Dr. Don Tyndall


    s09 e04

    Controversies & Iatrogenic Events

    Sharing Knowledge Pros/Cons & Type II Transportations


    s09 e05

    File Movement & Learning

    Manual and Mechanical Options & Endoruddle Recommendation


    s09 e06

    AAE & Endo/Perio Considerations

    Annual Meeting & Root Amp, Hemisections & Implants, Oh My!


    s09 e07

    Knowing the Difference & Surgery

    Case Discernment & Lateral Repair


    s09 e08

    Fresh Perspective & Apical Divisions

    Fast Healing & Irregular GPM and Cone Fit


    The Ruddle Show

    Commercial Trailer S09

    Watch Season 8


    s08 e01

    Endo/Perio Considerations & Recent Article

    Crestal/Furcal Defects & ProTaper Ultimate


    s08 e02

    WaveOne Gold

    Special Guest Presentation by Dr. Julian Webber


    s08 e03

    Microscope Tips & Perforation Management

    Q&A and Crestal & Furcal Perf Repair


    s08 e04

    Knowing the Difference & Calcification

    Esthetic vs. Cosmetic Dentistry & Managing Calcified Canals


    s08 e05

    Tough Questions & Sealer-Based Obturation

    The Loose Tooth & Guest Dr. Josette Camilleri


    s08 e06

    AAE Discussion Forum & 3D Irrigation

    Trending Topics & the SLP EndoActivator


    s08 e07

    Working Length & Microscope Tips

    Determining Accurate WL & Microscope Q&A, Part 2


    s08 e08

    Artificial Intelligence & Common Errors

    Incorporating AI & Endo/Restorative Errors


    The Ruddle Show

    Commercial Trailer S08

    Special Reports


    special e06


    As Presented at the John Ingle Endo Symposium


    special e05


    The Importance of Simplicity & Getting Back to Basics


    special e04


    Personal Interview on the Secrets to Success


    special e03


    The Launch of an Improved File System


    special e02


    The Way Forward

    Watch Season 7


    s07 e01

    Articles & Preferred Access

    Writing Projects & Ruddle’s Start-to-Finish Access


    s07 e02

    Patient Protocol & Post Removal

    CBCT & the Post Removal System


    s07 e03

    Avoiding Burnout & Ledge Management

    Giving New Life to Your Practice & Managing Ledges


    s07 e04

    Start-To-Finish Endodontics

    Special Guest Presentation featuring Dr. Gary Glassman


    s07 e05

    Laser Disinfection & Obturation

    The Lightwalker vs. EdgePRO Lasers and Q&A


    s07 e06

    Extra-Canal Invasive Resorption

    Special Case Report by Dr. Terry Pannkuk


    s07 e07

    GentleWave & Microsurgery

    Every Patient Considerations & Surgical Crypt Control


    s07 e08

    Artificial Intelligence & Endodontic Concepts

    Update on AI in Dentistry and Q&A


    The Ruddle Show

    Commercial Trailer S07

    Watch Season 6


    s06 e01

    Comparisons & NSRCT

    Chelator vs NaOCl and Managing Type I Transportations


    s06 e02

    Special Guest Presentation

    Dr. Marco Martignoni on Modern Restoration Techniques


    s06 e03

    International Community & Surgery

    Breaking Language Barriers & MB Root Considerations


    s06 e04

    Launching Dreams

    ProTaper Ultimate Q&A and Flying a Kite


    s06 e05

    Rising to the Challenge

    Working with Family & Managing an Irregular Glide Path


    s06 e06

    Controversy… or Not

    Is the Endodontic Triad Dead or Stuck on Semantics?


    s06 e07

    Endodontic Vanguard

    Zoom with Dr. Sonia Chopra and ProTaper Ultimate Q&A, Part 2


    s06 e08

    Nonsurgical Retreatment

    Carrier-Based Obturation Removal & MTA vs. Calcium Hydroxide


    The Ruddle Show

    Commercial Trailer S06

    Watch Season 5


    s05 e01

    Common Endo Errors & Discipline Overlap

    Apical and Lateral Blocks & Whose Job Is It?


    s05 e02

    Post Removal & Discounts

    Post Removal with Ultrasonics & Why Discounts are Problematic


    s05 e03

    EndoActivator History & Technique

    How the EndoActivator Came to Market & How to Use It


    s05 e04


    New Disinfection Technology and Q&A


    s05 e05

    Exploration & Disassembly

    Exploratory Treatment & the Coronal Disassembly Decision Tree


    s05 e06

    Advancements in Gutta Percha Technology

    Zoom Interview with Dr. Nathan Li


    s05 e07

    By Design... Culture & Surgical Flaps

    Intentional Practice Culture & Effective Flap Design


    s05 e08

    Workspaces & Calcium Hydroxide

    Ruddle Workspaces Tour & Calcium Hydroxide Q&A


    s05 e09

    Cognitive Dissonance

    Discussion and Case Reports


    s05 e10

    50 Shows Special

    A Tribute to The Ruddle Show’s First 5 Seasons


    The Ruddle Show

    Commercial Intro S05

    Watch Season 4


    s04 e01

    Tough Questions & SINE Tips

    Who Pays for Treatment if it Fails and Access Refinement


    s04 e02

    Endodontic Diagnosis

    Assessing Case Difficulty & Clinical Findings


    s04 e03

    CBCT & Incorporating New Technology

    Zoom with Prof. Shanon Patel and Q&A


    s04 e04

    Best Sealer & Best Dental Team

    Kerr Pulp Canal Sealer EWT & Hiring Staff


    s04 e05

    Ideation & The COVID Era

    Zoom with Dr. Gary Glassman and Post-Interview Discussion


    s04 e06

    Medications and Silver Points

    Dental Medications Q&A and How to Remove Silver Points


    s04 e07

    Tough Questions & Choices

    The Appropriate Canal Shape & Treatment Options


    s04 e08

    Q&A and Recently Published Articles

    Glide Path/Working Length and 2 Endo Articles


    s04 e09

    Hot Topic with Dr. Gordon Christensen

    Dr. Christensen Presents the Latest in Glass Ionomers


    s04 e10

    AAE Annual Meeting and Q&A

    Who is Presenting & Glide Path/Working Length, Part 2


    The Ruddle Show

    Commercial Intro S04


    The Ruddle Show

    Commercial Promo S04

    Watch Season 3


    s03 e01

    Treatment Rationale & Letters of Recommendation

    Review of Why Pulps Break Down & Getting a Helpful LOR


    s03 e02

    Profiles in Dentistry & Gutta Percha Removal

    A Closer Look at Dr. Rik van Mill & How to Remove Gutta Percha


    s03 e03

    Artificial Intelligence & Endo Questions

    AI in Dentistry and Some Trending Questions


    s03 e04

    How to Stay Safe & Where to Live

    A New Microscope Shield & Choosing a Dental School/Practice Location


    s03 e05

    3D Disinfection

    Laser Disinfection and Ruddle Q&A


    s03 e06

    Andreasen Tribute & Krakow Study

    Endodontic Trauma Case Studies & the Cost of Rescheduling


    s03 e07

    Ruddle Projects & Diagnostic Imaging

    What Ruddle Is Working On & Interpreting Radiographs


    s03 e08

    Obturation & Recently Published Article

    Carrier-Based Obturation & John West Article


    s03 e09

    Retreatment Fees & the FRS

    How to Assess the Retreatment Fee & the File Removal System


    s03 e10

    Research Methodology and Q&A

    Important Research Considerations and ProTaper Q&A


    The Ruddle Show

    Commercial Opener S03


    The Ruddle Show

    Commercial Promo S03

    Watch Season 2


    s02 e01


    Product History, Description & Technique


    s02 e02

    Interview with Dr. Terry Pannkuk

    Dr. Pannkuk Discusses Trends in Endodontic Education


    s02 e03

    3D Disinfection

    GentleWave Update and Intracanal Reagents


    s02 e04

    GPM & Local Dental Reps

    Glide Path Management & Best Utilizing Dental Reps


    s02 e05

    3D Disinfection & Fresh Perspective on MIE

    Ultrasonic vs. Sonic Disinfection Methods and MIE Insight


    s02 e06

    The ProTaper Story - Part 1

    ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos


    s02 e07

    The ProTaper Story - Part 2

    ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos


    s02 e08

    Interview with Dr. Cherilyn Sheets

    Getting to Know this Top Clinician, Educator & Researcher


    s02 e09

    Broken Instrument Removal

    Why Files Break & the Ultrasonic Removal Option


    s02 e10

    3D Obturation & Technique Tips

    Warm Vertical Condensation Technique & Some Helpful Pointers


    The Ruddle Show

    Commercial Promo S02


    The Ruddle Show

    Commercial Opener S02

    Watch Season 1


    s01 e01

    An Interview with Cliff Ruddle

    The Journey to Becoming “Cliff”


    s01 e02

    Microcracks & the Inventor's Journey

    Ruddle Insights into Two Key Topics


    s01 e03

    Around the World Perspective

    GentleWave Controversy & China Lecture Tour


    s01 e04

    Endodontic Access

    What is the Appropriate Access Size?


    s01 e05

    Locating Canals & Ledge Insight

    Tips for Finding Canals & the Difference Between a Ledge and an Apical Seat


    s01 e06

    Censorship in Dentistry

    Censorship in Dentistry and Overcooked Files


    s01 e07

    Endodontic Diagnosis & The Implant Option

    Vital Pulp Testing & Choosing Between an Implant or Root Canal


    s01 e08

    Emergency Scenario & Single Cone Obturation

    Assessing an Emergency & Single Cone Obturation with BC Sealer


    s01 e09

    Quackwatch & Pot of Gold

    Managing the Misguided Patient & Understanding the Business of Endo


    s01 e10

    Stress Management

    Interview with Motivational Speaker & Life Coach, Jesse Brisendine


    The Ruddle Show

    Commercial Opener S01

    Continue Watching


    Behind-the-Scenes PODCAST Construction

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    08.31.2023 Update



    02.02.2023 Update



    03.03.2022 Update


    Happy New Year



    Behind-the-Scenes Studio Construction


    The Ruddle Show
    Season 11

    Release Date Show Get Notified
    SHOW 91 - Delving Deeper Again
    Financial Investing, the Tooth or Implant, Accessing & Flashing Back
    SHOW 92 - Artificial Intelligence & Disassembly
    Differentiating Between AI Systems & Paste Removal
    SHOW 93 - The ProTaper Ultimate Slider
    Special Guest Presentation by Dr. Reid Pullen
    SHOW 94 - Cracked Tooth Syndrome & Resorption
    Endo History and "Through & Through" Management
    SHOW 95 - The "Look" & Disinfection Q&A
    Is the "Look" Controversial & Ingle Symposium Questions
    SHOW 96
    To Be Determined
    SHOW 97
    To Be Determined
    SHOW 98
    To Be Determined
    SHOW 99
    To Be Determined
    SHOW 100
    To Be Determined
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