Clifford J. Ruddle, DDS, discusses predictably successful endodontics in the context of preserving healthy tooth structures...
Interview with Dr. Terry Pannkuk Dr. Pannkuk Discusses Trends in Endodontic Education
This show welcomes a special guest endodontist, Dr. Terry Pannkuk, who tells us a little about his endodontic journey and gives us his opinion on some key issues. Further, Dr. Pannkuk discusses his educational company, Pure Dental Learning, and how education is evolving. The Good News/Bad News in the wrap-up will leave you feeling neutral. Ha!
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INTRO: Brief Introduction
Welcome to The Ruddle Show. I'm Lisette and this is my dad, Cliff Ruddle. How are you doing today?
I'm doing just great and I'm really excited to be here with you.
Yeah, we do have a very exciting show for you today. We have a special guest, Dr. Terry Pannkuk; lots of information to cover, so we're going to get started right away.
SEGMENT 1: Interview with Dr. Terry Pannkuk
It is with great pleasure that I have a good friend of mine, Dr. Terry Pannkuk, with us here today. And Terry and I go back a lot of years, actually decades, and we have a lot of stories we could tell you. But I just wanted to have Terry on because he's a great friend, he's a consummate clinician, he's a teacher, he's a writer, and maybe even a little inventing. So we're going to talk about some of this today; I just see he was a little surprised there; maybe I wasn’t supposed to say that he just invented the future. But anyway, I have a series of questions and Terry is going to share a little glimpse of his life with us, so let's get started.
Well Terry, you're here with me today in Santa Barbara, but where were you born and kind of how did it all get started?
Well I was born in Santa Monica. My father was an Iowa farmer, my mother is a Texan from El Paso. They met when my father went to Fort Bliss for missile training school, and they wanted to go to Paradise. So they moved to L.A. like a lot of people did in the '50s and they were a little disillusioned. It was a little bit bigger; my dad wanted to recreate Iowa so we moved north to Thousand Oaks which was very rural in those days, and we had horses, chickens and it was just a lot of open space. And so that's where I grew up.
He was an engineer, right?
He was an engineer.
So probably for our audience, back in this era can we say that a lot of people came out to start some of the big space companies and aviation and - ?
It was big in those days.
Yeah, very good. Well Terry, I think growing up you were probably playing some sports, right? Can you tell us a little bit about what the sports were and maybe something that might have actually happened during sports that had nothing to do with sports that might have led to something else?
Well I loved sports. And I was what you might call a hyperactive child; I was curious and adventurous and would take dares. And I played baseball, basketball, and later on, golf. And my Little League coach, Dr. Ray Johnson, was a dentist and kind of my role model. And on Halloween night around 1968 I got hit by a car, did a face plant, broke both condyles and knocked out my two front teeth, which were [inaudible]. And the technology in the '60s for replanting teeth wasn't what it was today, so I lost those teeth, and I lived in the dentist's office and had endodontics at a very early age.
Wow! How old were you roughly?
10 years old.
And did your baseball coach/dentist, was he telling you things about what he was doing?
Oh yeah, and he was a USC grad -- very diligent, very much a perfectionist. I could tell when I went in there sometimes – he was having good days and bad days because he was trying – he was very diligent and trying hard. And I can relate to that now why he seemed like he was in different moods.
But I thought what a great environment – I always had great dental experiences as a child – and it basically saved my face and my dentition so it was a big influence in my life.
And there was even another episode of trauma, right?
When I as about 18, again being kind of aggressive and competitive in baseball, I was diving for an outfield fly, jumped, hit the crossbar of the chain link fence, and the dentistry that my parents had just paid for was on the ground. And so they weren't too happy, and so I had another cycle of dentistry and another cycle of root canal treatment on a few chipped, broken lower incisors in addition to a new bridge. And so I had endodontics as a personal experience at a very young age.
You know it's interesting. I'm now talking to our audience about this guy right here. When you hear these stories about hustle and extension and placement, maybe we now understand more about Terry the endodontist because it's this tenacity and a lot of times that perseverance that I have noticed and appreciated as the professional.
Okay, so moving on. You played sports and you were growing up and you were in the dental chair as much as you were in a school room is what I'm thinking.
That's probably so.
To go with my education.
College -- what happened? Where'd you go?
I went to UCLA undergrad, and I had a lot of fun as an undergrad. I wasn't quite as studious at college as I was later on and that's where I met my wife Diane.
Well when you were at UCLA did you play any sports there or was it all school?
I played a lot of intramural sports. I played basketball and tag football, even though I wasn't supposed to. I actually had a kidney removed when I was 8 years old also. I had a congenitally malformed kidney and I was told never to box, never to play football. But I loved tag football and I did that anyway.
Is this why only a few short years ago you were considering hang gliding?
Yeah, I did hang gliding for a little while. But I've calmed down; I'm a little risk averse these days because I'm older.
Well we're older. Okay, so you finished UCLA, but were you thinking dentistry because of your childhood experiences?
I can't remember when I did not want to be a dentist.
Your dream career?
When I was young, I just really kind of idolized my baseball coach, my dentist. And I thought this would be a really cool thing to do and I just kind of never wavered from wanting to be a dentist. And being an endodontist came a little bit later.
Now that you wanted dental, what school and why?
Well I went to Georgetown because I was having so much fun at UCLA that it was one of the few schools I was accepted at. And it would happen to be the most expensive school in the country at the time and so it wasn't on everybody's first choice. But it was a fantastic clinical program. We did a lot of restorative, a lot of surfaces had gold; very similar to USC at the time.
What did Diane do back there while you were in dental school?
Well we were dating prior to my – at the time I was being accepted to Georgetown. And so I said honey, why don't we move to Georgetown together and move cross country? And she said do I look stupid? And so then I proposed to her, because she wasn't going to just move there. And so we got engaged and we got married at the Christmas vacation between my freshman year.
Very cool. And then what did she do back there?
Well, she had her sociology degree from UCLA and was very interested in business. Her father was an attorney. And so she got into George Washington; she got her MBA in procurement and contracts. And she actually got a job with the Air Force negotiating billion dollar contracts; it was very popular at that time, the main project was GPS which was top secret, and the Star Wars program that the Reagan Administration was dealing with.
Wow, that's cool. Well you guys are a pretty impressive couple. So you finish up dental school and what's in your mind? Are you going to head back and start general practice, or what was next?
Well I was influenced by Michael Fabio in the clinic at Georgetown. I was thinking -
Who is Michael Fabio?
He is a Boston University endodontist who was a teacher in the clinic when I was at Georgetown. And I became interested in endodontics having had so much experience with the procedure on myself, and he said the only place to go is Boston University. You have to study under Herb Schilder; he is the guru. And so I looked into it. I was a member of Ed Pinnick study group as a student at Georgetown and would go to the meetings. And I got accepted – I had an interview at two schools, University of Penn and Boston University. And I'll never forget interviewing with Leif Tronstad. He said – you know I had pretty good scores on the DAT and had very good grades at Georgetown – a little different than UCLA undergrad – and he said would you like to go into academia? And I go Hell no; I want to be a clinician. And so I kind of negated my option [Laughter]
And so the first question Herb asked me in my interview there was like so where else did you apply? And I knew from all the students at the clinic, don't tell him you applied anywhere else. But I violated that rule and I said I applied to University of Penn and he says oh, you did? And he said how did that go? I said well Dr. Tronstad asked me if I wanted to go into academia and I said Hell no; I want to be a clinician. And he went ah, that's right. Sort of a snort.
Isn't that where he went though?
Herb went to Temple and was influenced heavily by Morton Amsterdam was one of his mentors and Louis Grossman. So the whole Penn academic.
Restorative, endo. I knew he was doing Morton Amsterdam's endodontics so I knew he was doing some tough cases.
Well when you were back in Boston, you know I remember one time when Phyllis and I were back in Boston; we went and spent the day. It was called A Day with Herb Schilder. So he invited us to come back and spend a day, and you know what that's about, we won't even go into it. But anyway, we're back there watching a typical day in his life, and I'll never forget on his desk he had several pictures of his residents. And he kept saying "look at those legs; look at those legs; those are legs!" And we're going like yeah, those are legs, Herb. But anyway they all had something in common; they had running gear on and they were runners who he had apparently convinced to run the marathon with him. So tell us – I think you got caught up in that.
Well I wanted to succeed and impress Herb. And even though I was asthmatic and one of the slowest base runners you could possibly have on a baseball team -
He was a catcher on a baseball team. So okay, go ahead.
Catchers don't require as much speed. So I was a slow base runner, and I had asthma. But I go I'm going to start running because I need to do this to be successful in Herb's eyes. And so I started running like half a mile around the block, and it would be very snowy. So since it wasn't very warm, it was kind of easy on the lungs, the cold weather. So I go well this is great, and I moved it up to a mile a day in the mornings. And before I knew it, I was running like five miles a day. Then I was running like 10 miles three days a week. And on the weekends, I'd do longer runs and really get what's called the proverbial "runners' high". So I think the endorphins were starting to kick in and I actually started for the first time in my life enjoying running. And then I ran in the Cape Cod Marathon and actually finished it. And then I ran in the Boston Marathon, back of the pack; didn't finish it the first year and then finished the Boston Marathon the second year that I ran.
What did you learn about running the marathon, besides running?
That it's exhausting. You're beat up and it's a struggle. And the uphill is a lot easier than the downhill because of the long strides at the end. But it was quite an experience and the comradery was great; a few of us ran together. And Herb would always cut out at the 16 mile point and the rest of us would go on. But he was a serious runner and his son was a fantastic marathon runner and ran all the time; still probably runs to this day.
Interesting. So you ran and got your certificate in endodontics. And of course I'll tell the audience, for the general dentists that maybe don’t know this, at the time Terry trained and then when I trained – I went to Boston, but I was at Harvard – and my mentor was Al Krakow, that was Herb Schilder's second student. But one thing that we like about Boston is there was this philosophy of preparing canals. And there was this huge emphasis even back then – Herb always said “cleaning” but it could have been clean and disinfection today – and then filling root canal systems and warm gutta percha and all that. So you just got baptized in that and then you left. And were you going to stay back East or were you going to – what was next?
Well my wife is a southern California girl.
And you kidnapped her.
And I kidnapped her. And she wanted to go home; the kidnapping period was over. And so we moved back. She got a transfer from Hanscom Air Force Base in the Boston area to the Space Division down in Newport Beach and so we had our move paid for and we moved down there. We lived in Culver City one year and I worked in Thousand Oaks for six months and then I migrated up to Santa Barbara. Thousand Oaks wasn't quite the sleepy little town that I grew up in and so we moved further north, and Santa Barbara is beautiful and that's where I've been ever since.
Now I'm going to separate endo for just a second. And maybe I'll say a word or two and then say a sentence. Horseback riding; did you ever do any of that stuff?
I grew up horseback riding. We had a horse, we had chickens. My father wanted to recreate Iowa in Thousand Oaks. It was a nice rural environment in those days, very similar to the Santa Ynez Valley near us now. And so yeah, I used to go horseback riding; that was just part of my life. My children don’t really know much about that, but we took them on a ride several times and they liked that. My wife also grew up horseback riding, so we do that a little bit. Not as much today as we did earlier.
You know Terry, there's a sport – and I don't know if a lot of the audience would know; only your best friends would know – but you're a prolific golfer. And for a guy that practices endodontics fulltime and like long hour days, it's amazing – I don't even know if I've got the right words, but you're close to a scratch golfer or something like that.
Well I was better earlier. When business is good, I'm a lousy golfer and when business is bad, I'm a much better golfer because I can practice.
Okay. Well can you tell us two or three of the courses that were like bucket list type stuff?
Well, the wonderful thing about golf is the comradery, and some of my best friends that I've had for years – we've gone on golf trips together; gone to Scotland and played the old courses in Carnoustie. And one of our members at my club is a member of Augusta; took us all to Augusta and one of the few people that I know that can say that they've played Augusta four times.
Do you want to tell us about Ray's – is it Ray's Corner?
Ray’s Creek, the Hogan Bridge; it's all just – it's iconic.
We have you I think on that bridge; we'll show the audience. Well what about Pebble Beach and Spyglass?
Played Pebble Beach, Cyprus Point; fantastic courses. But a lot of us – you know I had a group of friends; we'd always try to play some great courses and it's just a great experience; great bonding with your friends.
Well you know I never did golf and I now refer it all out, and I refer it all to Terry, to my golfer. Well didn't you take a special cruise into Southeast Asia and volcano country?
That happened to be one of our golfing groups. A person contracted with Seabourn Cruise Lines in the 1980s, so 1980s prices for a millennium cruise. And so there were 250 of us and we cruised from Singapore to Bali and did all the Indonesian Islands in that area over the millennium. And it was a very special treat to be anchored off the volcano Krakatoa on New Years' Eve of the millennium and watch the smoldering volcano and have a party. And it was just quite an experience; quite an amazing excursion. We went to Komodo Island and got to see the Komodo Dragons and some of the indigenous peoples on some of the islands like Wombat Island and Sumba. And that was a bucket list trip that I'll probably never do again; that was amazing.
Wonderful experience. I've been to Southeast Asia and down through that part of the world, and imagine we could tell and be at it for all afternoon.
Fantastic experience. I love Asia.
Do you fish?
Love fishing. Don't get to do it as often as I'd like. I'm not a great fly fisherman but I like putting a line in the water and I love when a fish strikes your fly and I'm very good a losing a fish off the line.
Well I have down here fishing; you like boating and we talked about running, golf. We talked about – oh, mountains and snow; do you snowboard, ski, any of that stuff?
Growing up I didn't have a lot of opportunities to ski or be in the snow because we lived in Southern California and my family, they weren't skiers. But later on in life I tried skiing. And I realized because I surfed a lot that I was better at snowboarding, so I began snowboarding in my 40s and enjoyed that. And I haven't done that recently, but I was probably more of a snowboarder than a skier because an average snowboarder looks a lot better on the snowboard than an average skier, elegance-wise.
Yeah? Well you know we've talked about several things in recent days. We've hung out and talked about politics and '80s stuff and ADA stuff. But I didn't do this to you on purpose and this is a little curve ball. So for our general dentist colleagues, they always want like a trick or a tip or something that will add meaning to their life. Or maybe some little tiny thing as simple as like isolate the tooth. So can you give us three tips, maybe in a sentence each one, and then of course, they can follow up with you. Well on the next segment we'll talk about your educational center; how they can even get tapped into more. But right now have you got like three little tricks for general dentists? And endodontists; I mean endodontists sometimes can benefit.
I would say the key to treating simple cases and complex cases is (1) having immaculate isolation with a rubber dam; spend time to make sure the rubber dam fits and seals so that saliva isn't seeping through. Do whatever it takes to get good access. If you have to prescribe Xanax to relax the muscles, place a bite block; access is everything. And then actually spend a lot of time on the access cavity prep so that you have direct lines, no ledges. The time you spend refining the access pays huge dividends later in the case. And so those would be my three tips.
Those are excellent tips. Because if you're working through a good spacious access cavity – not too big, not too small, just right – everything fallows with greater predictability.
Exactly. You know that more than anyone Cliff.
Well I did a couple accesses I recall; one was out the side of the roof and one was through the floor. But you'll help me on that later.
Okay, we – I told you a little story about Phyllis and me and this special course we went to, and you said I'm a guy who lives right now. So I had a question here; what do you want to be remembered for? I don’t want to say you're gone because I've lost too many people in the last three months, but assuming you're going to live for 1000 more years, what would you like to have the world of endodontics or your family remember you as?
Well I struggled over that question when you asked me that, because I don’t think I ever think of being remembered. I live pretty much in the now and I'm focused on the now thinking about what is the right, appropriate thing for me to be doing right at this moment. And there were a lot of ambitious climbers trying to climb the summit of Everest and they're now frozen corpse waypoints. And I don't want to be remembered as a waypoint for those in the future that want to summit Everest. I just hope that I'm creating paths for people and with my friends and my colleagues; that we're all kind of sharing the same journey together. And I don’t really look in the rear view mirror to the past that much, although I certainly respect people like Herb Schilder and have been influenced by great mentors as we learn from history. But as far as how I want to be remembered, I'm not looking at my past.
My wife makes fun of me because she says you don't remember when we did this? Sometimes my past is just a blur to me; it may be old age. But I think I'm just focused on now; don't really think about being remembered. I hope my sons, my gene pool carries on and they have a wonderful life and success. I'm a spiritual person; I believe there's something else. And I just believe this journey will continue on and what do here is for now, and for others that are making that journey, and we'll just keep moving forward into the future.
Thanks Terry. Okay, so I hope you've really enjoyed getting a little glimpse of this guy. You know he's my personal endodontist; he's helped me out. My daughter Lisette; he's helped her out on three teeth. Two of them were bicuspid teeth and they were – they had a lot of root curvature. Forget canal curvature; they had a lot of -
I was sweating bullets on that one!
Yeah, she had bad s-shaped roots. And then of course my daughter got into trouble on another tooth and I don't think you were available; you were out of town – probably lecturing – and went to another endodontist. And I have all the technology in the world, but I want the audience to know. A lot of the technology is an adjunct to good, solid thinking, being very precise in how you approach your work. So this is Terry Pannkuk and I hope you've enjoyed our time together. And we're going to talk to him a little bit more in the next segment. So right now let's take a little break, and thanks so much Terry.
Thanks Cliff. It's a pleasure being here; it’s an honor.
SEGMENT 2: Trends in Education
Well that was a great interview. I really enjoyed learning a little bit about your journey and getting a glimpse into your life. So today we want now to talk about the present state of dentistry and endodontics in particular. Obviously technology has greatly evolved over the years and techniques have changed. But we really want to focus today on how endodontic education has evolved. So can you start by telling us a little bit about your educational company, Pure Dental Learning?
Pure Dental Learning was basically my attempt to just combine academicians, students and clinicians together to having an interactive educational experience. And it evolved as kind of an endodontic library of case studies, and then we also have Webinars that are fully interactive. So we try to encourage the people that participate in these online Webinars to interrupt the speakers, ask some challenging questions, no holds barred, and the interactive element of all these venues. And at some point maybe we'll make it an endodontic encyclopedia if people contribute enough cases and we get good literature references.
I think we have some slides that show a little bit more about the philosophy behind the company or the education; how you see it. So why don't you just explain to us a little bit more what this graphic means?
Well I like to think in terms of Venn Diagrams, and everybody has their own bias and perspective. And a clinician tends – once you graduate from dental school, they don't always, we don’t always read the literature to the same diligence that we did when we were studying, and you tend to believe that what you see, what works in your hands is the way it is. If you see it, you believe it. So your version or your bias of how you perceive the truth is empirical; what you see in your practice with less literature support. And then sometimes you might have a harebrained idea that you think this ought to be a good thing to try, and your creativity – which isn't always appropriate – may come into play as theory to contribute to what your perception of the truth is.
And I think that you're required to have some CE, but maybe you just do that to get it out of the way and you're really just focused on your practice.
A lot of times dentists will go to CE courses as a golf trip where they'll show up and get their CE credits and then get the course code and then go play golf. But what I really like about PDL is we have a lot of residents; we have a lot of students that are very passionate and very enthusiastic. And that's very fulfilling and it's very enriching to have people that are very passionate, learning, asking questions. And that kind of rubs off on some of the clinicians that may become a little jaded when they see these excited young people.
Oh definitely I would think that would be the case.
You know, being excited, and it brings everybody together and a little bit more excitement comes to learning.
You find that when you're teaching, right; that the excitement of the students – because I know you work with a lot of residents – how they like renew your excitement as well.
You know having the chance to help somebody in life – whether it's a patient or whether it's a student that is sincere and wants to learn – is one of the biggest joys that Terry and I would get out of teaching. Because you see the “aha” moment and the lights go on. Maybe by the end of the day they're showing you the images that they've done and they're getting it, and it brings us a lot of joy, right Terry?
Keeps you fresh; keeps you enthused. And we do this and we don't always get paid for our time out of the office, but it comes back in spades because you come back refreshed and you're just more successful in your life overall because of just having this energy that you keep infusing into your practice.
You know Terry, one thing – I don't think we thought we were going to talk about his – but don't you think from a teaching perspective it's so healthy, because every single case you're thinking this needs to be fully documented.
I don't know what I'm going to discover here, but it's going to be maybe something that I'll see once in my life.
Exactly. And I don't think I documented as well earlier in my career; mainly because of technology. We didn't have digital imaging and all the cameras that we have today available, and it was a big deal to have a film camera and remember which cases were on the roll and organize that later. So my early cases in my career – probably the same for you – are not as well documented as later in your career where it's just easier to document. So I just snap pictures of everything when I'm working now and it's filtered out later.
Let's take a look at the next slide where we showed the academicians' perspective.
Well there's always this with academicians and clinicians, where they just don’t have an appreciation for each other many times. And the academician, the person that's at a school, probably doesn't have as much clinical input into their knowledge base as a clinician, but they're guilty of not having the clinical experience in the same way the clinician is guilty of not keeping up the literature. And so they believe that the literature is the Holy Grail of evidence and they think that that comprises of the truth.
And so really, that's another bias; that's another false perspective. We think the truth is more based on our bias.
It's interesting that the initial reaction is for them to be kind of opposed to each other instead of wanting to bring all their knowledge together.
Well that's the way it should be. It should be a balance of all perspectives; we should bring all the knowledge together so that we can all learn from each other.
So let's look at the reality, okay? Explain a little bit about this.
Well I think the reality is that we don't understand the truth as well as we think we do.
Like neither side.
Neither side. And so we're always coming up with surprises in science; we're always changing the paradigm in science. Things change and evolve, and things we believe one year may be different the next year as more evidence comes out. So really if we share our knowledge, share the empiricism, share creativity theory, and keep up with the literature and most importantly, critically evaluate it so you can weed out with intelligence the false literature that's not designed very well, that will give you the best appreciation of the truth.
Now these interactions or intersections of these circles in the Venn Diagram are arbitrary and so it was just kind of my biased perspective of what I think each contributes to the truth. But I think we can pretty much say none of us are perfect or understand all knowledge.
I do notice about your diagram is that they participate in the truth, but they just don't all encompass the truth. So maybe that's because we're all subjective human beings, so even if we read the research and even if we are doing practice and talking to students, we still can only approach the truth?
We can only approach the truth. And it's a constant battle. We're trying perfection; we need to have 100% focus, 100% planning. But we're still not perfect; we're all human beings. And so shared knowledge is more powerful than individual knowledge.
I really like – so you're just emphasizing shared knowledge, and you're not just focusing in one area, but getting your knowledge from different places.
Absolutely, and that's the beauty of interdisciplinary care. We as endodontists have tunnel vision into a canal and into a tooth. But until we start working with the orthodontists, the oral surgeons, the periodontists and the prosthodontists (restorative dentists), we get a better feeling of how important this tooth is, what our roles should really be in the overall treatment plan. And that's the beauty of interdisciplinary dental care; it's the best high quality care a patient can receive.
So I'd like to pound on this one more time. So Terry's talking about interdisciplinary treatment and study clubs comes to mind. I want to tell one on him. We hadn't thought about saying this, but he was gone last week out of Santa Barbara and he was in the greater Phoenix area and apparently the Seattle Study Club. I might have this wrong, so you don't have to even correct me. But there were groups around the country and I think there were six teams.
So 18 teams, cut down to 6, cut down to 2, cut down to 1.
And so it was fun being on that team, just the collaboration with other specialists. It's a fantastic experience to be involved in study clubs I think.
What I wanted them to hear though, Terry, is you went down there with a maxillofacial surgeon; you went down there I think with an orthodontist, a prosthodontists, you were the endodontist. And the thing is by everybody sharing the case through their perspective and their frame of reference, you being to find, as we've been talking about, the edges of the truth and they begin to show up. So they went from a great number of people from around the country and your team is down to the final 2?
But the audience voted on the second round.
Oh, okay. But I'm about two generations older than Terry, but when I first came to town I joined a study club; there were 10 of us and we met six times a year – once a month, six times a year – and we had all these disciplines and everybody'd just throw up a case and we'd all talk about it. But you begin to discover those things and how they all interrelate. Maybe we can have Isaac find the area of commonality. It might teach us a little football right in that green/blue area.
But the more you work together, the more that commonality emerges. And so I think that's very important.
What else do you got for us?
Well why don't you tell us more about the Webinars and how you see those as being – how you see them as they should be run versus other ones that you've seen that you try to make yours different from.
Well I think what PDL is different and in what way PDL is different is that we try to be as interactive as possible and we don't try to control the narrative of the presentation. So we want everything to be challenged and we want everything to be shared and so that everybody has a chance to answer questions.
Can I cut in? So I was a moderator a couple times when you were doing live demos. And one was – can we just say a shape/clean/pack on a maxillary second molar? And then the other one was a microsurgery procedure on a root approximation to the middle foramen, mandibular bi. And what I wanted to tell the room is I'm a moderator; I'm supposed to take pressure off of Terry. I'm supposed to – he's working, right; he's the surgeon in this case. He has his earphones on and he's taking questions from around the country, and he's doing his bevel. He's working on his apicoectomy. And remember we kept beveling because there was a little micro fracture.
Anyway, long story short is this guy – I think we'd call him a one-man band. You had your assistant and you had a patient, but you were like inbound, outbound, and you were doing the work. It was a beautiful experience.
It was a little bit of a show. But the patient was carefully selected and we basically selected the situation so that it could be maximally interactive. And a lot of problems with a lot of live stream is there's a lot of dead time, and we didn't want that. We wanted questions being asked, we had people at the conference table live, we had yourself asking questions as a moderator, and we had online people feeding me questions through the headphones.
Barry Vilkin was there.
Yeah, your old pal and my pal. And so I think if you choose the right case that can be a powerful learning experience for people, where questions come out; it's not a controlled environment, the procedure will happen, and anything unusual that happens can be picked apart, discussed for maximum learning at that point, and that's the whole goal of PDL.
You had told me something that I thought was interesting, because I've heard my dad say in the past that he's seen a Webinar that just went horribly wrong and just kind of ended in like you're just cringing and it's sort of a disaster. But then you had mentioned that you actually want things to go wrong because then you can have a chance to – why don't you tell us about that.
Well I don't know if I want it to go wrong, but I don't mind controllable complexities that are unplanned occurring, because that's where the real learning occurs. And I think everybody wants to see – they don't want to see a pristine, routine case that there's no learning. They want to see a case with complexities and they want to see how somebody with experience handles that. And that's how they learn. And they want to have a chance to ask why did you do that; like right then and there. And you don't what to have to think two hours later, like I forgot the question. They want to ask questions immediately; like why are you doing that? And so the participants in these Webinars have the opportunity to ask immediate, real time questions, which is kind of unique in today's dental education setting.
See that chaos is very different than the chaos he's describing. He's describing a clinician who has to make decisions by the moment. And when you're doing microsurgery with CVCT and all this pretreatment planning, there's a lot of things that come up – bleeders; everything that you wouldn't expect necessarily can happen. And of course with a lot of experience you start to say I saw it all until you didn't.
So that to me is chaotic; that's controlled chaos. My complaint is the ones that are showing and not teaching. I want to make a critical distinction between show and teach. Show is a lot of times a new technology. Well we all love technology so it's okay to show new technology. But the technology is an adjunct. It should not be there to cover up deficiencies in primary training. So when I saw chaos, I saw using new technology, bleeding problems, and cuttrol going down the canal, coagulation left behind and packing a few minutes later. So to me it was more showing than it was telling, or teaching; instruction.
Yeah, that's not complexity management, that's crisis management; unnecessary crises. And so that's not what we want to show. We want to show proper planning, proper selection of the patient for that venue, and the way a case is really managed by somebody with experience.
You know Terry, many years ago – and I told this on another show already so I won't repeat it; sorry, I don't want to bore you to death. But the Air Force has an expression, “Flawless Execution.” So I was eating with these officers that fly the F-18s and F-22s, and they're like half your age. And I said God, no mistakes ever? They said oh no, we make lots of mistakes. But he said we're always adjusting and we're always solving problems as they occur. So that's what you were doing when I saw the surgery.
Well a crisis mistake in that instance would be a crash and death. And management of complexities means you're still flying and you're fine. So it's not so bad.
Okay, let's move on and talk a little bit about the discussion forums that are out there. Why don't you tell us about the different kinds of endodontic discussion forums that are out there? Are there any that you prefer, or do you participate in them?
I try to participate in as many discussion forums as I possibly can.
He's internationally famous, so everybody listen very carefully about discussions. Go ahead.
Well I love discussion forums. It's an opportunity to challenge and debate, and I'm a big fan of Socratic debate; which isn't always politically correct or popular these days. And to just have a pool of people all sharing the same profession, having different experiences, and to challenge ideas is a wonderful learning experience for me; to learn more from other people and to have my own ideas tested. I think that is critical so the discussion forums are fantastic.
You like the feedback don't you?
Love the feedback.
And you know one thing Terry does – and I think he's sometimes misunderstood – but sometimes when we attack a philosophy or a treatment or a thinking decision, we're not attacking the person; we're trying to get better with the procedure. And that's where colleagues need to be able to hold two conflicting ideas at one time; that's called maturity. Where you can hold two ideas – like maybe he's not attacking me; he wondered why I had bleeding and I was still stuffing something in the retro prep and there was blood everywhere. So then I get – I could take it wrong, I can get angry about it; he's attacking me, Terry wants to note.
You know we just lost Kobe Bryant. And I read something last night in the paper and I've heard you say it three times today and we haven't even talked about it. He said that after he left the game the most important thing would be if he would work with you and train with you and work out one-on-one was if you were curious. You've mentioned that word "curiosity" three times. I think sometimes great people are curious about things and that's what makes them try to discover the truth or the edges of the truth.
Yeah, I've always been curious and sometimes too curious – probing into areas that people don't want to answer the question. And so that's a very interesting thought. Yeah, I think it's very important to be curious. And if somebody is different, it's even more intriguing to find out how they are different than how you are.
Well I think that three pretty hot topics right now in discussion forums -
Oh geez, hot topics Terry.
Are probably minimally invasive endodontics, GentleWave and obturation with a single cone and BC sealer. So why don’t we give each of you an opportunity to speak just uncensored for one minute about Gentle Wave first. So do you want to start dad?
Let our guest go first – or are you going to put me on the spot on this?
And I'll time you.
Then I'll decide how truthful I want to be with my responses.
So one minute; start now.
Okay. I am receptive to all technology and new technology. But in order to incorporate it into my practice and actually use it on patients and have a degree of confidence, I either have to have my own logic satisfied, and there has to be adequate scientific evidence. And the problem with GentleWave and the Sonendo is they're very aggressive; they're trying to set this device up as a new standard of care – which I disagree with because they really don't have the science to back it up. They have science, but they require universities and anybody who buys their device to sign a contract; and so they kind of shoehorn their employees into controlling the data, control the results, which is not independent research. So there are no real citations out there on the GentleWave device that are unbiased and actual third party research.
Time; perfect. Okay! Now you go, Dad.
Oh. Well I want to be kind and I'm going to be honest. Terry will know that your pop believes in root canal systems because we were all trained in Boston. He went to BU; that's the guy – Schilder – who pretty much mapped this out for us in terms of the anatomy, the breakdown, the disease flow and what the assignment was. And he invented all kinds of words and vernacular, and a few people – a very few people – embraced that.
So I was a couple generations before him. I came back to Santa Barbara and I was filling root canal systems. So the first thing I'd like to say to both of you – and you'll agree I think – I've been getting anatomy off of every shape canal, 2 or 3 POEs off of virtually every shape on an average for decades. I never used GentleWave. So I get insulted when the impression is finally for the first time in your life, doctor, you'll be able to treat a root canal system, because we have a system.
So I didn't say very much. See she's really telling me to be quiet. This is a pesky alarm!
By the way Isaac, I do have the sound off.
So I guess I'll just finish by saying lots more will be coming; many episodes will return to this topic because it's like the news. Sometimes the news doesn't play out in one cycle; we're going to hear it for a few weeks. We're just getting started with GentleWave. We're just getting started.
So now in the interests of time. I'll let you have one more minute on either minimally invasive endodontics or BC sealer and single cone obturation. Which one do you choose?
I'll pick minimally invasive endodontics.
Okay, and go.
Okay, minimally invasive endodontics is a great concept in the sense that we want to conserve dentin and not remove any unnecessary dentin. I think of endodontic access as a SEA-access, which I call strategically extended endodontic access. You don't want to remove dentin where you don't need to, but you have to remove dentin to get a direct line to the canal to remove, clean, shape and eliminate debris. And if you don't do that it's like having a small opening. The debris is just going to churn in a container and not be removed unless you can actually flush it out through an adequate occlusal opening. And the occlusal third of the crown is very expendable tooth structure because that preserves your feral at the cervical area where you can have a restoration and still have an adequate restoration, with the tooth having structural integrity. So that's it.
Okay. And now what would you like to talk about?
Well I'll just repeat a joke.
Well you can take one minute on either minimally invasive endodontics or -
Oh, I'll take the single cone and the BC sealer. Obviously a lot of this has arrived because of the triad. We prepare the canal; we don't agree on the terminal diameter of the taper. Cleansing there's all kinds of methods; chemicals and agitation devices and then of course filling root canal systems. So as we change any one of those in the model, we change the others. So as the shapes have gotten smaller, they can't get the armamentarium sufficiently deep to mold the cone and adapt it into the apical configuration. And so I think I don't like the cone column. But the most important thing I don't like is a sealer that is immiscible in any chemical and cannot be completely removed mechanically. And I wonder when I talk to people like Josette Camilleri, a world authority in BC sealer; what we're going to see in 3, 4, 5 years. Terry will tell you almost anything works for 3, 4, or 5 years. And what separates out excellence from mediocracy is time.
And time. Okay, so thank you both. I think that we really appreciate to hear your just candid opinions on those things.
Thank you Cliff. It's an honor to be here today.
I just want you to finish by maybe telling us how you see the future of endodontic education.
Well I’m an optimist, and an extreme optimist. I believe that one person can change things. And one problem we have in education today is bias and corporate bias influencing the narrative of education and distorting the truth that we talked about earlier. So I think in the future we have to balance this out better. We need technology; we need innovation. But we also need to have fair, non-fraudulent science in education. We can't have every corporate employee shoot more into these programs, creating what is being taught and what the curriculum is. We have to be teaching more diagnosis and treatment planning; things that are not tied to a product. And so I see the future as balancing this better, and I think those of us who are passionate about education and want a balanced education can push this forward and we can change.
The pendulum swings back and forth. You know they were probably too provincial in the past and we're now too wild west with just free associated influences.
Cowboy endodontics. So we need to get back to a balance. And students and clinicians will be better in the future for it.
Well thank you; thank you both. I think that pretty much is it; we're out of time now. But I do think that – well I forgot what I was going to say – but I'm actually very inspired by your passion. So thank you for coming on the show today and thank you both.
Thank you ,Cliff.
Thanks Lisette; thanks Terry. We'll have you back because you have a lot to give. We'll have to get you over there on Set B so you can get up there and do a little teaching on the chalk board.
We do have some cases that Dr. Pannkuk has done on our website in the show notes. So if you want to look at some great endodontics, please feel free to go there.
And visit Pure Dental Learning.
CLOSE: Good News/Bad News
Okay, so we're going to close our show today with a segment we call Good News/Bad News. And what's going to happen is I'm going to name a product or a concept and then my dad is going to tell you the good news about it and the bad news about it. But he's going to be very concise, so just so you know, we might talk in a lot more detail in a future show about some of these things. But just to close this segment, it's going to be pretty concise; the good news and then the bad news.
So here we go. Cheap files.
The good news is they're cheap. The bad news is they unwind and you replace them frequently.
System based endodontics.
The good news for system based is that it's a concept where files, gutta percha, paper points, all have some interrelationship with each other. The bad news is most companies haven't discovered how to actually deliver it.
So kind of like theoretically and then reality.
Intriguing that it can probably clean quite well. Bad news is that we could already clean quite well.
Technology in general.
The good news is it holds enormous promise to be either easier, better, faster. Bad news is a lot of people pass on training and hope the magic technology can overcome the deficiencies in training.
Minimally invasive endodontics.
Noble concept is the good news. The bad news is we argue about something about the size of a human hair.
Oh the good news is it's accessible. It's easy for clients in their own world. Bad news is be sure you know who you're training with.
And also there is something good – there is something positive about getting out in the community and interacting; like Terry was talking about the importance of dialogue. It seems like you lose a little bit of that with online education.
You know there's still nothing like a hug and a handshake and sitting by somebody during a study club and visiting about a case where there's a break. You learn a lot physically getting together.
Okay, BC sealer.
The good news is it's a good repair material. It's in that silicate family of like MTA. Bad news is we have to worry about solubility, we have to worry about pH, and we have to worry about degradation; and we don't know that yet.
Lastly ,The Ruddle Show.
The good news is I'm sitting right here about 100 yards from my house. The bad news is staying on time.
And with that in mind, we are out of time for today. So thank you for watching and we hope you enjoyed it. See you next time on The Ruddle Show.
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Exploratory Treatment & the Coronal Disassembly Decision Tree
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Zoom Interview with Dr. Nathan Li
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Intentional Practice Culture & Effective Flap Design
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Ruddle Workspaces Tour & Calcium Hydroxide Q&A
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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.