University of Pennsylvania Samuel Kratchman, DMD Department of Endodontics and Microscope Training Center School of Dental Medicine Saving Teeth! Saving Teeth! +90% Conventional Treatment Endodontic Therapy Nonsurgical Surgical Retreatment Retreatment +80% ? 35 year history of implants 1980: Implants land in the USA and a Trying Period of acceptance 1990: EXPLOSION-implants solve all dental problems. Extract/Implant!! 2000: Extract and Implants continue with irrational exuberance 2010: It is not what it is cracked up to be…start to think! Peri-implantitis 2015: Critical Analysis of Per-implantitis…call to action to save teeth 2015: Systematic review shows peri-implant mucositis and peri-implantitis ranges from 19%-65% (Derks and Tomsai) Conclusion: Teeth even compromised because of periodontal disease or endodontic problems may have a longevity that surpasses BY FAR that of the average implant. (Salvi et al, 2014, Klinge et al, 2015) Misch et al., Implant Dentistry, 2008 Dr Kim Dr. W. Giannobile and N.P.Lang; Journal Dental Research, 2016 13,000 year follow up!! Periradicular surgery, no matter how sophisticated or advanced, is NOT a substitute for conventional endodontics. Anatomical Tables – W. Hess 1917 Why does nonsurgical treatment keep failing? ENDO > 20 Years ago ?? Failing Periapical Pathology Nair, 1996, 2004 Periapical Pathology Abscess 12% Granuloma 73% True Cyst 9% Pocket Cyst 6% According to Dr. J. Simon during the USC Conference in 2008: 24% of periapical radiolucencies are cysts which do NOT respond to root canal therapy but need surgical intervention along with RCT Periapical Pathology Pocket Cyst True Cyst Continuity with the RC Self-sustained 6% 9% Nair PNR Int End J 1998 An inflammatory apical cyst is a pathologic cavity in an area of apical periodontitis lesion, and is lined by non-keratinized stratified squamous ephithelium Radicular Cysts Cystic cavities lined by Lumen surrounding epithelium epithelial strands accompanied by granulomatous tissue H&E, original X325 X350, inset 31000 X 31000 The epithelial lining of radicular cysts is Accumulation of foam cells thought to arise from epithelial cell rests of and scattered PMNs Malassez Riccuci et al, OOOE, 2006 Cone Beam Computer Tomography n = 17 Detection of liquid content in cystic cavity Histology after biopsy 13 / 17 lesions had same diagnosis by CBCT and biopsy 76 % in agreement Simon et al. J Endod 2006 Rosenberg J Endod 2010: Must biopsy/histology; dont depend CBCT Bornstein J Endod 2015: PA films overestimated cysts 20.7%, CBCT overestimated 28.4%