From: Terry Pannkuk
To: ROOTS
Sent: Tuesday, July 13, 2010 10:30 AM
Subject: [roots] Today's First Long Term Recall

I treated this cracked tooth with compromised pericemental dentin in 1998.  Two strikes against it.
It still there, functional and healthy with a well-made gold crown.   Notice how the straight angle
from 1998 shows the narrow diameter of the ribbon-shaped root canal system.  The slightly off-angle
one today makes it look wider.  Depending upon the angle I take I’m sure I could get a different
opinion on whether it’s hogged-out.  Clinical opinions are like a-holes, everyone has one,
right Glenn? - Terry



Yep yeo! Did Ben Johnson know you were using rotaries in 1998?

Other than the light-to-moderate GG use in the coronal, the endo on this case could be
straight out of a FastTrack course.

The access is large, and gouged.  Strike #1.

The saving grace on this case is that the PCD has not been violated by the endodontic shape, and the
case has full gold which minimizes the axial reduction.  Also of note is what appears to be an amalgam
core, and a fairly flat occlusion further protected by a third molar.- Textbook Clark&Khademi

Sure the PCD looks perfect, gouged by the guy who placed the amalgam, deep distal post with a post prep drill,
extensive caries wipe out of the distal and complete distal amalgam margin.  I build this type of case up with
bonded amalgam myself these days with no post and wouldn’t have let the referral do the build-up. .

This is purely a fortuitous anecdote and an unlikely success.

I was using rotaries too much during that period, my later results and earlier results were better.

Below is an attached 14 year recall on the same patient I saw today with a missed DB because I was trying to be
Khademi-like in my distal extension.  There had been distal periodontal surgery with an amalgam repair of
root caries.  I didn’t want to pop it out.  I wasn’t as aggressive then as I am now and would have extended
the access to make sure I could see the distal better removing all restorations that might restrict my access
and cause me to miss something (like this confluent deep loop of a DB canal. (I took a CBCT of this one because
I’m treating #14 which is more broken down than any of the other previous teeth I treated (#15, 2, and 18).
Definitely a suspicious recurrent lesion on #15 and if there was any clinical evidence/symptomology I’d take
it apart and retreat it.   Re-entering it now will likely render it nonrestorable.  I’m letting sleeping dogs lie.
Check out the transverse section series.  Starts off as a single buccal orifice branches off to a distinct DB loop
a few mm’s down, then joins back. There is no doubt in my mind I wouldn’t be looking at that light diffuse PA
radiolucency and wondering what I left percolating down the DB track if I had extended the access and not
wimped out trying the please the perio guy.  Definitive endo first, eliminate disease, then the other clowns
can do their dirty work.  My job is not to leave loose ends.  The more difficult the access and the more complex
the anatomy, the more a important it is to perform a SEE access.  I’m simply “lucky so far” this patient hasn’t
manifested clinical disease with this tooth. - Terry




Here’s the third tooth I treated on this woman that I recalled today. I treated #2 in 2003.  (7 year recall),
much better shaping and I had pretty much given up on the rotary bullshit at this point. Notice the apical
internal resorption defect in the palatal system. The obturation replicates Hess anatomy more than a skinny
Tulsa shape.  The CT exam is much more appealing and didn’t give me reason to worry about future bone loss/disease
progression or equivocal subclinical signs and symptoms typically pawned off as hypochondria or simply a
fussy continually complaining patient.   Interestingly this patient decided not to have the crown and still has
the amalgam build up that was placed 7 years ago.  Fused, unfavorable root form, deep distal root caries,
unprotected cusps, in occlusion Tell me how this pericemental dentin is so protected.  Tell me how this tooth
survived the Khademi-Clark Dogma of Dentinal Destruction?  It even survived my own current dogma of not filling
a necrotic tooth in one visit.or did it?.....maybe that PDL space widening at the distal root apex wouldn’t be
there if I had placed CH for a month. Barnett’s full influence hadn’t kicked in to make me a total 2 visit
Nazi until about 2004 ( a year later) - Terry