In a seriously damaged tooth, one of the questions patients ask most often is “should I have a root canal treatment or have it extracted and get an implant?” Evidence shows that outcomes of properly restored root-treated teeth and implant-supported restorations can be close to each other in some conditions; the decision depends on the condition of the tooth (Iqbal & Kim, 2007).

Conditions that support saving the tooth

• Enough healthy tooth structure remaining
• Roots and surrounding bone being preserved
• A restorable tooth structure (Kidd et al., 2003)

Conditions that suggest extraction and an implant

• Vertical root fracture (Tamse et al., 1999)
• Severe, untreatable endo-periodontal lesions (Kang et al., 2019)
• A tooth too broken down to be restored

Implants are not free of complications either; possible problems after an implant should be known (Resnik & Misch, 2018). See our implant treatment page for details.

Questions asked in the decision process

The basic questions to ask when deciding on a seriously damaged tooth are: Can the tooth be restored again? What is the condition of the roots and surrounding bone? Is the tooth fractured or cracked? What is the state of gum disease? What are your general health and expectations? The dentist evaluates the answers at the examination with X-rays and, if needed, tomography (Kidd et al., 2003).

Why is “extract and place an implant” not always right?

Keeping the natural tooth in most cases helps preserve the surrounding bone and gum structure. If the natural tooth can be treated properly, this option may not require implant surgery, bone grafting or additional procedures. However, in situations such as a seriously fractured tooth, root crack or severe endo-periodontal lesion, the chance of saving is low and extraction may be more reasonable (Tamse et al., 1999; Kang et al., 2019).

Realistic expectations of an implant

An implant is not an exact replacement for a natural tooth; it requires surgery, a healing period and prosthetic stages. The possibilities of surgical and prosthetic complications have been described in the literature (Resnik & Misch, 2018). Therefore categorical statements such as “always implant” or “always save the tooth” should be avoided.

Suggestions for a sound decision

• Ask for a written treatment plan and the pros and cons of the options.
• Get a second opinion if needed.
• Consider cost as a whole, including maintenance and renewal, not only as the first procedure.

Frequently asked questions

Which lasts longer?

It varies with the person and the tooth; no general superiority can be claimed.

How is the decision made?

With clinical examination, radiography and gum/bone evaluation.

Should I get a second opinion?

It is a reasonable approach before major treatment.

If root canal treatment fails, is an implant needed?

Retreatment or surgical options can be evaluated first; extraction can be the last option.

Is root canal treatment done on a cracked tooth?

The depth and location of the crack are decisive; in some cases the tooth cannot be saved (Tamse et al., 1999).

How much time should I take to decide?

If there is no urgent infection, it is reasonable to allow time to think before deciding and, if needed, for a second opinion.

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References

• Iqbal, M. K., & Kim, S. (2007). For teeth requiring endodontic treatment, what are the differences in outcomes of restored endodontically treated teeth compared to implant-supported restorations?. International Journal of Oral & Maxillofacial Implants, 22(Suppl.), 96–116. PubMed ↗
• Tamse, A., Fuss, Z., Lustig, J., Ganor, Y., & Kaffe, I. (1999). Radiographic features of vertically fractured, endodontically treated maxillary premolars. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 88(3), 348–352. PubMed ↗
• Kidd, E. A. M., Smith, B. G. N., & Watson, T. F. (2003). Pickard’s manual of operative dentistry (8th ed.). Oxford University Press.
• Resnik, R. R., & Misch, C. E. (2018). Misch’s avoiding complications in oral implantology. Elsevier.
• Kang, M. K., Trabert, K. C., & Mehrazarin, S. (2019). Endodontic-periodontic lesions: Pathogenesis, diagnosis, and treatment considerations (Chapter 46). In M. G. Newman, H. H. Takei, P. R. Klokkevold, & F. A. Carranza (Eds.), Newman and Carranza’s clinical periodontology (13th ed., pp. 498–505). Elsevier.

Note: Book chapter references follow the page ranges of the publisher’s edition; article links open the matching PubMed record.

This article is for information only and is not medical advice. See your dentist for diagnosis and treatment; no outcome is guaranteed.

This page was reviewed by Dr. Dt. Mehmet Fuat Bozaba, periodontist.