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Endo tips    Better Endo    Endo abstracts    Endo discussions

Ledges and perfs - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are -
From: Terry Pannkuk
Sent: Friday, November 13, 2009 10:26 AM
Subject: [roots] Groundhog Day Again

The time loop is the from the retreatments that keep coming in each day from the access preps that look
like this with ledges and perfs. Seeing more conservative access articles in Dentistry Today just insures
that we're going to get a Ground Hog Day time loop of constant poor-to-guarded prognosis retreatment
consultations, more blackeyes on endo, more fodder for implantologists, along with more requests leading
to attorney depositions.  These are constant conflicts distracting from real patient care.  The two bottom
images are from my last patient this evening.  The request was to keep the access conservative or
"biomimetic" because the referral had built up the distal resorption defect, prepped the tooth, and taken
final impressions, sent to the lab.  If that is what's meant by restorative driven then it's going to drive
all the other team players to the insane asylum; it's clearly "KIS ASS" philosophy (Keep It Simple And
Simply Stupid". Maybe I'll refer the case to David Clark so he can keep the orifices real tiny on the distal
and not dislodge the glass ionomer distal wall.  The patient was also led to believe that he wouldn't need
a real consultation because the radiographs and photos were sent to me by email.  It's Groundhog Day again
alright, it's just that it's 1960 repeating, not 2010.  Bioschmeglmics is nothing new.  It's just lowering
the bar again - Terry

Kaufman's support not withstanding, speaking your mind and your passion is NOT going to get you a position in any post-doctoral endo grad program in the US or lower Slobovia. A sad but truism in a society that will elect a Sarah Palin and a Michele Bachman. That being said, take your stand against minimalistic biomimetics in the print media can only fight fire with fire.........oldest story in Red Adair's book, you put out a full blown oil well fire with blow-out fire fighting technology. We all posture on this forum in one form or another, it's the reality of anonymity in the online world.... That being said anon, you can make anything unsubstantiated look sexy if it is big enough and shiny enough. ......and can associate it with enough toys. Strategic extension or straight line or glide path or shoot the moon access preparation...........if it can't be replicated and substantiated by the vast assemblage of practitioners, it's bogus hocus pocus. But at least the guy that can do it once get's to say he did it like _)(*&_(*#Q@)(* - ah the wonder of the lemming...... Publish Sir Pannkuk or run the risk of perishing on the pitard of the pontificating pundits - Kendo Isn't this print? .....I typed it out so you can go to the left corner of your window under the "file" toolbar, drop down the box and print it anyway you want. :) - Terry > Publish Sir Pannkuk or run the risk of perishing on the pitard of the pusillanimous,putative, pontificating pundits. - Molar Del Sud LOL, humor keeps one sane. :) - Terry Nice alliteration - pitard is the pits though ... or is that petard is the pets ...? - Simon Bender Terry: I agree with you but am going to add something to you. YOU ALONE are the controller of your own fate. If you allow referrals to send you cases with these stipulations then you are part of the problem instead of striving to create a solution. I mean this in the best possible way, you may not agree with David Clark and his concepts of conservation of tooth structure and if this is the case you must EDUCATE your referrals. They must know the reasons for why you feel the way you do. Sit down with them, send them an email, take them for lunch, explain your concepts to them. Then you will be waking up to Groundhog Day ( one of the best movies by the way) . The thoughts you bring to Roots are bright, opinionated , and sincere- but the reality of the world is that if it is truly important for you to get great referrals and to stop the degradation of your discipline, the beginnings start with you. Look in the mirror, are any of the reasons for these problems a lack of education of your referring dentists. If its not - get better dentists to refer to you. Simple really - The humble GP- Glenn Glenn, I appreciate your opinion and respect your opinion, but there is a culture of lazy thinking, lazy ethics, and intellectual cowardice that is a runaway train, not just in our profession but in others as well. I am not particularly happy with myself for being so cynical, sarcastic but I am even more disgusted with many of our colleagues in the sense that under financial pressure they bend to serve their own interests violating patient trust and appropriate treatment. Rats jumping ship leaves a frantically working crew to sink. Dentistry Today is simply a mindless pop culture dentist's guide to flash what sounds and looks better than real science to its readers. One cannot attribute distortion to every single article written in Dentistry Today, no more than one can say every dentist logging on to Dental Town is a quack, BUT supporting these publications and forums in a broad sense feeds the beast. Preaching ethics, disclosing reality, and highlighting mounds of empirical evidence that strongly supports successful dentistry in the face of intense well-capitalized distortions is like pissing in the ocean. I'll simply state that bullshit is better capitalized with an extraordinarily successful marketing program than the truth. It's just the way I see it and it isn't a pretty picture....sorry to show you things that are ugly and not pretty - Terry Terry, well, i guess it is not the arrows, it is indians... i.e. it is not biomimetics, it is a "clownician". The case you just posted - hey, who in normal mental state would do what the referral have done??! I mean, GIC build-up for crown prep, prep and final impression sent to lab prior endo is completed??? That was a clown on the other end, not the philosophy itself. BTW, did you do the case? What did you tell the referral? - Dmitri It's the clownicians with crap bows, crap arrows, crap concepts, and crap skills. Biomimetics is the problem because it enhances "Clownsmanship" by potentiating endodontic treatment errors and reverse-rationalizing crap standards of care as acceptable. It is very appropriate to blame materials and philosophy for results when those self-proclaimed gurus identified with them show such crap results. I would have been absolutely embarrassed and would have lost sleep over all the cases Clark showed in the Dentistry Today article, if they had been regrettably mine. This is 1960's endo philosophy all over again. I thought we had successfully discarded these dysfunctional clinical treatment concepts decades ago - Terry In an effort to keep it simple. It is a bad thing to cut a big hole in a tooth looking for the pulp chamber. Dr Clark say's that dentists should use a microscope to find pulp chambers, because it helps the dentist to NOT cut such a big hole. Also using smaller drills, will help the dentist to cut away less tooth. And with front teeth, when we cut our hole higher towards the incisal edge, we cut away less tooth. Does that sound like some evil conspiracy???? - Dr James Maroney Not an evil conspiracy, just a less effective way of doing things. You need to cut into the cingulum prominence to clean the lingual aspect properly; cut way up at the incisal and the edge will be weak. As for the size of the bur - please! The largest drill available wouldn't make a big enough access in a molar. Maybe it's not as simple as people might like to pretend - you need a hole exactly the right size AND shape to optimize the shaping procedure. He's right about using the scope though - Simon Bender There is a balance that is missed here. It isn't simple. One size fits all for these guys. It seems that most of Clark's Khademi's endo treatments are under prepared apically leaving overhanging ceilings over orifices. which allows you no chance of achieving a clean apical third with today's current technology. Direct line access is essential to apical third management otherwise you're just churning crap and tumbling it around, not clearing it. The evil conspiracy is to kiss the ass of every goofball restorative dentist that doesn't necessarily want to be better but just wants things easy. I repeat that the big problem with "restorative driven" dentistry isn't that it is restorative driven, it's "clownician driven". If Dentistry was truly a team sport you wouldn't have clownicians exploiting other team members to make their phase of the plan easier and more profitable at the expense of proper treatment for the patient. Khademi and others keep putting words in my mouth, like "big" and "wide" access, I simply say strategically extended access is necessary to make sure endodontic treatment is complete and thorough. It is my very strong opinion that what they teach is making things much worse; I'm constantly retreating septic anatomy, poorly shaped cases every day. Here's another one from this afternoon below. The only way I can support my opinion is by showing you crap case after crap case I'm retreating every day. I wish these clownicians would just simply blow up these teeth with a large access to begin with so the patient can simply have the tooth extracted and implanted, instead of continually mutilating them through pea holes with ledges, blocks perfs keeping them in a chronically diseased state. Every single damn retreatment I do: Poorly extended access---->missed MB2's, lower ant linguals, upper bi buccals, lower molar DB's, etc. etc.---->pulp stones in the pulp chamber----->CAP's etc. etc. It is very predictably boring. I haven't even been in this case yet and I can tell you what the problem is (no sepsis control, no apical third management, no understanding of anatomy, and constricted, poorly extended access. To open up Dentistry Today and read utter crap after correcting these cases every single damn day makes one.....well let's say......crazy! :) Welcome to Groundhog Day, I'm just trying to run a new script online each day to see what prevents the accidents from occurring that I've already seen occur the previous day, which happened the same way the day before, and the day before, and the day before, and the day before, and the day before. :):):) - Terry This banter on access design is intriguing.........the minimalist advocates are again suggesting that use of a "scope" enables one to a) walk on water, b) walk on water and c) fly in the face of logic, engineering predicates and reality. The amount of coronal tooth structure affected by previous restorations, decay and trauma is a contributing factor to access preparation design, the limitations of metallurgy contribute based on the degrees of root curvatures and the planes of geometry of that curvature and on the day that an overhang with no foundational support is a "stronger" functional entity than modest divergence resulting in long axial vector directional force is the day Sarah Palin becomes president of the United States. I see no point in referencing the advocates, just another day in the guru factory........logic dictates that the degree of removal of coronal structure is analogous to the same concept of biomorphology and practicality that apical preparation should remain as small as practical and yet be sufficient to ensure literal hermetic sealing of the apical terminus. On what day with two moons in the night sky is it possible to imprint, template or cookie cutter a concept on any given tooth............Terry's description of strategic extension is logical , to attempt to emulate a concept of minimalistic access cavity preparation might make sense, provided the operator can replicate the tactile dexterity and manual skill set of the proponent. I would reasonably submit that reduction of the angle of interface of the long axis vector from the occlusal reference point to the interface of the point of most dramatic root curvature is the prime objective of any instrumentation technique. With NiTi instrumentation the hour glass iatrogenics of the days of Weine and Roses are subverted, however, minimalism creates an unnecessarily risky geometry that will not only potentiate inadequate cleansing due to the nature of the envelope of motion of any instrument rotating or reciprocating in the root canal space, but it will invariably lead the inexperienced to greater risk of iatrogenic accident. Idealize axial inclination, equilibrate occlusion, architecturally correct the soft and hard tissue foundation and restore with the greatest of accuracy, ensure a true Morse chamber axial chamber design.................what in bloody hell does minimalism have to do with an optimal functional's an excuse to get 15 minutes of infamy. What he said. - Kendo yes! the Morse does one connect these dots---the "calla lilly" recently bloomed and the minimalist access? has the flower died? - KendelG Twas a misstatement - twas the Morse Taper axial chamber design. Tarun Agarwal was on the other day........sincerely wish he had persisted. The ideal endo restorative continuum is the CEREC created restoration wherein the chamber is prepped to receive the inlay aspect of a CEREC restoration with cuspal wings to recreate occlusal anatomy....ideal monobloc. Dots that connect are cusp tip pulp horn orifice and protractor geometry or as Dr. P calls it SEE.... - Kendo Ken: I think that you are right but there are several issues to raising the bar of endodontics and one of the first and foremost is getting greater numbers of people to use loupes and then a scope. (INCREASE THE LEVEL OF MAGNIFICATION). This in itself will not ensure that people will do great endo but it is impossible to do some of what we see from Siju, Jorg , Sashi, Terry , Fred and so many others with naked eye. Endodontics is one of the few disciplines to have any research showing a greater amount of anatomy (pulpal tissue) discovered with the scope (Stropkos study amongst others) but the key would be to develop a university that would look at the crucial elements of how much magnification is enough, do the errors in preparation of access become less with higher levels of visual acuity. Do we reach a point of no increasing value to higher levels of magnification. Are iatrogenic errors ( I spent yesterday in an endo course watching case after case of great endo ruined by crappy restorative from post perfs to crappy margins) reduced with higher levels of magnification. I am in the beginning parts of trying to get UBC involved in magnification research, because for me its become such a huge part of what makes going to work enjoyable. You cant treat what you cant see. These are issues which swirl around in my meager brain these days. Its inherently something I know that the microscope is a tool ( as Terry says) but an indispensable one for endo and many other disciplines in our profession. It just makes the impossible .....possible. I for one think it is admirable that some (Clark and Khademi ) are trying to raise the bar in endo and get away from the 15 minute crap that makes the ENDO-IMPLANT algorithm so much more important and unfortunately it becomes the IMPLANT algorithm....... I see way too many half hearted attempts to save a tooth.....3 canals filled short.....fails, take it out. Shove in some shiny threaded stuff. And boy oh boy are there a huge number of vertical fractures now for the Implant gurus......its a great looking tooth with no xray but its yarded out and LOOK what a LOVELY CLEAN EXTRACTION. I am but a humble GP, someone who is proud of my efforts to become better at a discipline (endo) that I sucked at. I have been on Roots since the beginning and I have learned ALOT here. It was all learned to try and be better and to try and save more teeth. That for me is important, sadly at times today the tincture of titanium is shiny , alluring and fashionable, and its a hell of alot easier to slam one in without a scope. Just my 2 cents but please folks. As specialists you need to show what is possible to save teeth, its to easy for so many to show why implants are a better alternative - Glenn Fair enough :-) But, on the other hand, i see many pretty sufficient-size accesses... bearing all sorts of problems you named - missed anatomy, ledged, perfed, short, long - you name it. It is not the size of access per se - it is more the commitment of a clinician (or the lack of thereof). Say, if you "accuse" John and David of being too "biomimetic" - do you happen to retreat their cases? You happen to retreat cases from bozos, who's only concern is hour-production... isn't it so? - Dmitri Dmitri, I tend to refrain from attacking clinician's individual cases and naming names because all of us have tough cases and any selected single case may not be representative of an individual's potential, skill, and consistency of work. Similarly, I do not get to excited about those cases that are shown to be extraordinarily good for the same reasons in an opposite way. With that said, I rip the crap out of those presenting cases as a way to do something that I've found to be clearly in my opinion and reasoning to be wrong. I've spent years exploring different ideas and philosophies, and I am absolutely convinced that what they are teaching is absolutely wrong; I'm not timid about saying so, because it passionately disturbs me that so many people will be taught to take such risks and experience so many problems from such poor clinical recommendations. All I'm trying to do is support my reasons why. It's nothing personal against Khademi or Clark; in fact, I find David Clark to be a very nice guy to be around. I suspect he does beautiful restorative. Khademi's build-ups are wonderful. It's just that I passionately believe their cases that they think are good are crap. I am not really sorry for sounding rude and obnoxious because it is the only way I know how to directly make my point without mincing words. Many of these people that I beat up I really like, or at least used to like before they started hating me for my blunt opinions. - Terry Terry, it doesn't look like all the resoption was removed. What did you do with the resorptions? - Joey D I haven't started it yet, he's not scheduled until December. The plan is a covert op "seek and destroy" mission. These built up distal walls tend to accidentally crumble. :):):) - Terry I am not really sorry for sounding rude and obnoxious because it is the only way I know how to directly make my point without mincing words. Many of these people that I beat up I really like, or at least used to like before they started hating me for my blunt opinions. - Terry That's the problem and we have been in the profession for 20 years and see the same crud all the time. It's just a cycle of repeating crud. It's easy to say "Go get some good refering dentists". Honestly, I have found, the more I try to do what's in the patients best interest, the more I get pooped on by the dental profession. Good refering dentists are hard to come by. It's difficult sometimes to explain quality. It's difficult for general and referring docs to understand quality. The get bought into some line. In Phoenix right now it's a cut throat endodontic referal thing. Endodontists pandering to "I can do that molar in one visit in an hour" to guys who bought a CT and are doing DX by CT without doing appropriate pulp and periradicular tests. Dentists love fast and seem to not understand technology abuse. Even good referals love fast since they can put the crown on faster and get the revenue. Companies love to sell it. Witness the "anyone can do root canals with these instruments" with sayings such as "I did the entire root canal with one instrument" Instrumentation only get's 60 or 70% of the crud at best. Irrigation is needed ot get the rest. Time is an abosolute requirement to disolve tissue with copious amounts of NaOCl. I disagree with Terry that Dentistry Today and Dental Town feed the beasts. INstead, I look at these vehicles as selling what the profession wants to hear. How to make more money, How to do it more quickly, how to cheat around the edges often times. They are just giving the profession what the profession asks for. Look at the latest Dentistry today....did Dave Clark even make the cover? His article was hidden inside the issue. While I disagree with small "biometric" accesses, because very few can do it and find all the canals, and instrument them adequately, there is a place for that opinion. I don't see how things will change UNLESS our voice to change the status quo begins to reverberate to be more ethical, have that reality disclosure and work for long term success. WE have to turn ugly into more pretty. WE have to stop allow our profession to be used by well capitalized companies to distort the picture of reality we and our patients live in - Joey D Every single freakn' day I see this stuff referred to me, totally screwed up and unnecessarily so. I've developed zero tolerance for bad ideas that I've previously experimented with and now know better. When someone thinks they are setting the world on fire by promoting and selling these anciently discarded bad ideas, I want to scream..... I can't scream in front of my patients so I scream here at you............sorry. :):):) - Terry
Protaper flaring
6 yr old Empress
Cvek pulpotomy
Middle mesial
Endo misdiagnosis
MTA retrofill
Resin core
BW importance
Bicuspid tooth

Necrotic #8 treatment
Finding MB2 / MB3
Deep in a canal
Broken file retrieval
Molar cases
Pushed over apex
MB2 and palatal canal
Long lower third
Veneer cases
CT Implant surgury

Weird Anatomy
Apical trifurcation
Canal and Ultrasonics
Cotton stuffed chamber
Pulp floor sandblasting
Silver point removal
Difficult acute curve
Marked swelling
5 canaled premolar

Sealer overextension
Complex anatomy
Secondary caries
Zygomatic arch
Confluent mesials
LL 1st molar (#19)
Shaping vs Cleaning
First bicuspid
In Vivo mesial view
Inaccesible canals

Premolar 45
Ortho and implant
Lateral incisor
Churning irrigant
Cold lateral
Tipped to lingual
Acute pulpitis images

Middle distal canal
Silver point
Crown preparation
Epiphany healing
Weird anatomy
Dual Xenon
Looking for MB2
Upper molar resorption
Acute apical abcess
Finding MB2

Gingival inflammation
Irreversible pulpitis
AG BU ortho band
TF Files
using TF files
Broken bur
Warm technique
Restorative prognosis
Tooth # 20 and #30

Apical third
3 canal premolar
Severe curvature
Interesting anatomy
Chamber floor
Zirconia crown
Dycal matrix
Cracked tooth
Tooth structure loss
Multiplanar curves