“Save the Tooth” or “Choose an Implant”? — The Evidence for the Value of Preserving the Natural Tooth

Should a tooth be saved, or extracted and replaced with an implant? The more difficult the case, the more often this decision gives pause. In short, the long-term survival rates of a tooth preserved with appropriate endodontic therapy and of a single-tooth implant are roughly on par. There are, however, differences that the numbers alone do not reveal. This article summarizes the key evidence.

Survival rates are roughly comparable

In the systematic review by Iqbal & Kim (2007), the survival rate of restored single-tooth implants was about 95%, and that of endodontically treated teeth about 94% (both at roughly 6 years), with no statistically significant difference between them. In addition, Salehrabi & Rotstein (2004), analyzing large-scale data on approximately 1.5 million teeth, found that about 97% of teeth that had received initial root canal treatment were still retained in the mouth 8 years later. Contrary to the impression that “root-canal-treated teeth do not last,” teeth that receive appropriate treatment function over the long term.

There is a difference in the “post-treatment burden”

On the other hand, differences have been reported in the post-treatment course. In the matched-pair study by Doyle et al. (2006) at the University of Minnesota, favorable outcomes at 7–9 years were 74% for implants and 84% for endodontic therapy. Notably, additional procedures and complications after treatment were reported to be significantly more frequent in the implant group. In the 8-year comparison by Vozza et al. (2011), the figures were 83.3% for endodontic therapy and 80.8% for implants, with no significant difference. Even when survival rates are equivalent, the natural tooth may hold the advantage in terms of fewer subsequent interventions.

Points to keep in mind when reading these comparisons

• The definitions of “success” and “survival” differ between teeth and implants, making a simple numerical comparison difficult.

• Peri-implantitis has been reported to occur in about 9.7% of single-tooth implants within 5 years.

• Many of the endodontic cases included in meta-analyses used older techniques; contemporary treatment using the dental operating microscope and surgical endodontics (microsurgery) can lead to better preservation outcomes.

A message for clinical practice

What the evidence consistently shows is not “which is superior,” but rather that “when appropriately selected and performed, both can be expected to achieve high success.” However, once a natural tooth is lost, it can never be returned to a natural tooth. The two are not competing options but complementary ones. For precisely this reason, accurately determining — before extraction — whether “this tooth can be saved with specialized endodontic therapy” leads to the greatest benefit for the patient.

This article is a general overview based on major systematic reviews and prospective studies. The optimal choice in an individual case depends on the condition of the tooth, the remaining tooth structure, the pathology, and the patient’s systemic condition.

Key references

• Iqbal MK, Kim S. A review of factors influencing treatment planning decisions of single-tooth implants versus preserving natural teeth with nonsurgical endodontic therapy. J Endod. 2008;34(5):519–529.

• Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod. 2004;30(12):846–850.

• Doyle SL, et al. Retrospective cross-sectional comparison of initial nonsurgical endodontic treatment and single-tooth implants. J Endod. 2006;32(9):822–827.

• Setzer FC, Kim S. Comparison of long-term survival of implants and endodontically treated teeth. J Dent Res. 2014;93(1):19–26.