Deciding Between Root Canal and Implant

Root Canal or Dental Implant Choices

With advances in both root canal and dental implant technologies, the decision of whether to perform root canal (endodontic) treatment and retain a debilitated tooth, or whether to extract a tooth and replace it with an implant becomes more complicated. There are a myriad of variables and clinical factors to consider when counseling with your patients regarding treatment options. What is the best choice for an individual situation and represents the most ideal and predictable result can vary from case to case, and presenting the patient with a full understanding of the options, as well as the pros and cons of each treatment, is essential to establishing proper informed consent.

Root Canal vs. Dental Implant Decision Making

After acquiring all pertinent clinical data, including x-ray, periodontal, occlusal function, caries susceptibility, orthodontic, and systemic health records, a discussion can proceed debating the relative merits of each treatment. Conventional root canal treatment is considered most conservative, unless complex root anatomy or the need for apical surgery makes the endodontic treatment "heroic" in nature. Conventional root canals allow preservation of natural root structure and eliminate the need for a surgical procedure to extract the tooth, followed by an additional surgery to place an implant. Considering the patient's overall health profile, a surgical extraction and implant may be contraindicated. On the other hand, if a tooth is badly debilitated due to caries involvement or fracture, a root canal may not be warranted as the prognosis for the tooth is guarded and failure may lead to an even more difficult extraction involving minimal remaining tooth structure or fractured roots.

Is It Prudent To Perform Root Canal on Debilitated Tooth

Proceeding with root canal treatment on a tooth with distinct structural issues can often be characterized as "heroic" if the long-term retention of the tooth is not predictable, as root canal treated teeth become more desiccated and fracture-prone over the years. Some implantology surgeons even indicate that root canal-treated teeth are just space maintainers for implants to be placed in the future. Although clinical studies report excellent success rates and retention for root canal-treated teeth, it is the badly deteriorated tooth that presents the conundrum of whether to retain with a root canal and crown, or extract in favor of implant placement.

Implants also have very high rates of success today, but patient selection is still crucial to the success of any given case. Adequate bone levels, proper bone anatomy, and bone quality must be established, as well as adequate soft tissue health immediately around the implant site. Medications such as bisphosphonates may also present a complication to extraction and subsequent dental implant placement. Patients should also be informed of complications with dental hygiene associated with implant diameter, and the risk of peri-implantitis. Financial considerations should also be fully discussed with patients taking the risks of failure for both root canal treatment and extraction/implant placement into consideration. Many times the clinical decision will come down to patient tolerance for waiting up to a year to receive a new tooth while wearing an interim partial denture (if extraction, bone graft healing, implant placement, and osseointegration are considered) versus crowning a root canal-treated tooth in a week and having an immediately restored tooth.

Ultimately, the clinical decision to retain a debilitated tooth with root canal treatment versus extracting the tooth and replacing it with an implant is complex and depends on multiple factors and the clinician's best judgment. For a full discussion of the factors involved see our 2-unit CE course Implant vs. Endo: Treatment Planning