Dental implant vs. root canal, which makes the better choice? -

How to make an informed comparison of the two procedures. / Expected success rates. / A checklist of issues to consider.

Using dental implants as a way to replace missing teeth has gained widespread acceptance over the last two decades. And dental patients who are aware of the success of this technique may wonder:

  • "If my tooth is so damaged that it needs root canal treatment, why not just have it extracted and get a dental implant placed instead?"

We agree, this is a very logical question to have.

What needs to be considered when making this decision?

As the remainder of this page outlines, when deciding between the two there are some fundamental issues that must be weighed. They include:

  1. What's the likely success rate of each of the two procedures (research evaluating implants vs. root canals).
    • How might the specifics of your case affect the expected rates?
    • How does the dentist's level of training tend to affect case success?
  2. Clinical reasons why one approach might be favored over the other.
    • Case-specific treatment challenges.
    • Patient's needs and preferences.
  3. Relative cost effectiveness.

1) Dental implants vs. root canal treatment - Success rates.

Definitively proving which of these treatment options creates the better outcome is difficult. After all, if one of the procedures has been performed, it's impossible to know what the outcome of the other would have been.

However if the success rate of each is considered independently, they can be compared and you can come up with an answer, at least in general terms. And, for the most part, dental research tends to show that both treatment approaches can make an excellent choice.

Root canal treatment compared to a dental implant.

Dental implant vs. root canal treatment.

Dental research.

Study #1 -

Title: "Endosseous implants versus non-surgical root canal therapy: A systematic review of the literature." (Blicher 2008) [page references]

This paper reviewed published studies that either ...

  1. Evaluated the survival rate of teeth that had received root canal treatment.
  2. Evaluated the success or failure of dental implant placement.

Its findings were ...

  • The success rate for root canal treatment ranged between 92 and 97% (over a time frame of four to eight years)
  • The success rate for dental implants ranged between 95 and 99% (over a time frame of two to sixteen years).

These results suggest that the overall success rate of either treatment approach is fairly similar, although slightly favoring dental implants.

Study #2 -

Title: "For teeth requiring endodontic treatment, what are the differences in outcomes of restored endodontically treated teeth compared to implant-supported restorations?" (Iqbal 2007)

This paper, which was also a literature review, took into consideration 55 research studies that had evaluated dental implants and 13 that evaluated root canal therapy. It came to the conclusion that:

  • No significant differences in survival rates existed between the two treatment approaches (root canal vs. implants).

The paper continued by stating that a decision between the two should be based on factors other than just the statistical analysis of predicted treatment outcome (success rate). (See lower on this page for an outline of factors that should be considered.)


Together, the findings of both of these literature reviews suggests that either treatment option (endodontic therapy or implant placement) can make an excellent choice. However, this assumes that a proper standard of care has been practiced (see our next section).

And while there may be specific circumstances why one or the other might make the much better choice in any one situation (see checklist below), as a general rule neither has been universally proven to provide a significant advantage or be the preferred approach.

2) Maximizing your chances for a successful outcome.

a) Pick the proper clinician.

It's important to understand that different dentists have different levels of training. And with any case, but especially challenging ones, the knowledge and expertise of the clinician can significantly affect the outcome of the work that's been performed.

i) Clinician success rates for root canal treatment.

A study by Alley (2004) found that 98% of routine cases treated by endodontists (root canal specialists) were successful vs. 90% for those treated by general dentists.

[Beyond just increased training and experience, most endodontists incorporate equipment into their practice that general dentists typically just don't have. This includes a surgical operating microscope.

These instruments assist the clinician in identifying any minute root canals that might exist and this aids clinical results. After all, even the most talented general dentist can't successfully treat canals they can't locate.]

ii) Clinician success rates for implants.

Unlike the field of endodontics (root canals) that's been taught for decades, implantology (at least the way it's practiced now) is a much newer field. It's only been since the 1990's that it's been a regular part of the curriculum of dental schools.

Specialist vs. general dentist.

Early on, dental implants (at least the ones evaluated by the earliest longevity studies) where typically placed by dentists having a "specialists" level of training (either in oral surgery or periodontology). In comparison, nowadays its routine for implants to be placed by general practitioners.

It could be debated that collectively, the work performed by general practitioners doesn't equate to the high standard of care typically practiced by specialists.

  • A hint of this phenomenon might be apparent in data coming from Australia. There, the largest category of implant related claims against dentists (24%) is founded on errors associated with inappropriate diagnosis and case selection (Cohn 2005).

This is the type of error that might be more likely made by a less rigorously trained practitioner.

iii) Be a consumer. Ask your dentist questions.

We're not trying to suggest that general practitioners can't provide quality implant and endodontic services because that statement would not be true.

But what we are suggesting is that before accepting a recommended treatment plan, be a consumer first. Quiz your dentist about their experience in providing the proposed treatment.

A tooth that has root canal treatment and a crown.

A tooth that has had root canal and a crown placed.

b) With root canal, you must commit to complete treatment to reap the highest success rate.

Studies evaluating the success rate of endodontic therapy typically only evaluate those teeth that also had an appropriate dental restoration placed on them after their treatment was completed.

That's because it takes this combination to create the most predictable and lasting outcome.

Many endodontically treated teeth (especially molars) are lost because they were not properly restored. Failing to commit to having a suitable restoration placed (possibly a dental crown) may compromise the long-term outcome of your treatment.

3) If the success rates of both are similar, what other factors need to be considered?

The fact that both root canal treatment and dental implant placement have high and comparable success rates suggests that the decision between the two will need to hinge on other factors.

Checklist of issues:

Here's a list of factors and issues your dentist will consider when trying to come to a conclusion about what treatment approach makes the best plan for you. If you think possibly any of them apply to your situation, you should make a point of discussing them with your dentist.

a) How important is it to you to retain your natural teeth?

Generally speaking, the primary emphasis of modern dentistry is helping the patient to keep their natural teeth. And for this reason, when evaluating the question of extraction and implant placement vs. "saving" the tooth by way of performing root canal therapy, most dentists will likely lean toward the latter.

This of course presumes that performing the work, including rebuilding the tooth after its endodontic therapy has been completed, is expected to be routine (see our next section).

Advantages of "saving" your tooth.

While the following points may not be especially important in your case, there are reasons why retaining a natural tooth has advantages over implant placement.

  • The ligament that binds a tooth in its socket provides sensory feedback that helps you to control your jaw's movements (direction, speed, amount of force). And besides just assisting with normal function, this information also helps you to prevent problems, like overloading your jaw joint.

    We won't pretend that this is a big issue when just a single tooth has been replaced with an implant. But if enough teeth have been sacrificed, this loss of sensation can become significant.

  • Implants osseointegrate (fuse) with the jawbone. That means future orthodontic movement of it (i.e. having braces) is not possible.
  • There can be negative psychological effects associated with tooth loss. People tend to prefer the idea of keeping their natural dentition (teeth).

b) Clinical issues:

i) Can the tooth's root canal therapy be completed successfully?

Obviously, if the dentist expects that there will be significant challenges to being able to successfully complete the tooth's endodontic therapy, placing an implant will likely make the better choice.

a) Initial tooth treatment.

As mentioned above, routine conventional root canal therapy can be expected to provide a predictable and lasting outcome. Especially when the work has been performed to a high standard of care (see above).

Reasons not to treat.

Even so, circumstances may exist that will ultimately result in treatment failure. This can include significant cracks within the tooth or its root(s). Or internal tooth anatomy that's difficult, or even impossible, to adequately treat.

If the dentist performing the work is able to identify such problems, a recommendation of extraction and implant placement can be expected.

b) Teeth requiring retreatment.

Some patients face the decision of "saving" or "pulling" their tooth at that point when it's discovered that its original root canal treatment has failed.

Retreatment is less predictable.

While the success rate of a tooth's initial endodontic therapy can be quite high (90 to 98%, see above), with less than ideal cases (like retreatment) this number begins to fall. And especially in cases where surgical retreatment is required ("apical" surgery), the predictability of the procedure's outcome drops even further.

When it comes to retreatment, if it can be performed conventionally (through an opening created in the tooth) doing so may still make the best choice. But if surgical intervention is required (accessing the tooth's root via a gum incision and bone removal), extraction and the placement of an implant may make the better choice. (DiMatteo 2008)

ii) What will it take to rebuild the tooth?

Teeth that require endodontic therapy have frequently experienced some type of catastrophic event. This could include fracture or advanced tooth decay. If so, the question then becomes how involved will rebuilding it be?

Doing so may be fairly routine (such as dental crown and post placement). But in some cases additional procedures may be required too. Or conditions may be so deteriorated that rebuilding the tooth is impractical or ill-advised.

Complications with severely damaged teeth.

Dentists have specific rules they must follow when restoring teeth. With broken down ones, one of them is that the restoration placed must not extend so far underneath the gum line that it's close to the underlying bone. If this rule is broken, gum health around the tooth will be a perpetual problem, likely affecting the neighboring teeth too.

Additional procedures.

A surgical procedure, termed crown lengthening, can be performed to remedy this situation. But doing so removes some of the bone that supports the tooth (and usually from around the adjacent teeth too). Beyond that disadvantage, there's also the issue of the additional time (including healing time) and expense of performing this procedure.

Teeth that are easily rebuilt can make excellent candidates for being "saved." But if a complication exists, extraction and the placement of a dental implant may prove to be the more prudent choice.

iii) Does the tooth have good gum health?

If the tooth in question has advanced periodontal (gum) disease, extracting it and placing an implant likely makes the better choice.

That's not to say that patients who have generalized poor gum health make suitable candidates for implant placement. But clearly, if a tooth's compromised status cannot be corrected, "saving" it by performing root canal treatment makes no sense.

iv) What will be required to place an implant?

Just as natural teeth may require additional procedures to successfully repair them, dental implant placement may require performing additional procedures too.

The patient's jawbone may require tissue grafting or bone augmentation (such as a sinus lift procedure). If so, the case will involve added expense and time (including healing time). In comparison, retaining the existing tooth may make the more attractive choice.

v) Esthetic considerations.

Especially when a front tooth is the one being treated, factors involving the appearance of the procedure's final outcome will be a prime consideration.

a) Challenges with teeth that receive root canal treatment.

For the most part, improving the appearance of a tooth that has had root canal treatment is usually a fairly straightforward task. And in fact, even substantial improvements can be made if a dental crown is placed.

But in some cases, original factors like exceptionally poor tooth alignment may make creating the ideal esthetic outcome virtually impossible. In comparison, tooth extraction and replacement with an implant may be able to make this type of alignment change quite readily.

b) Challenges with dental implants.

Implant positioning.

When placing an implant, the dentist must adhere to rules dictated by characteristics of the jawbone (such as its shape, bone quality and position of nearby anatomical structures).

And in some cases, having to follow these guidelines may interfere with placing the implant in a position that's most ideal for esthetic purposes.

Implant / gum line concerns.

Another issue involves the region where the implant's crown meets the gum line. In some cases, it can be difficult for the dentist to make this junction look totally natural.

This consideration may make "saving" the tooth the better choice for people who display this area prominently when they smile (people who have a "skin grin").

c) Ask your dentist questions before your treatment begins.

You can expect that your dentist will be quite aware of the issues we have mentioned above. But what they might consider a minor compromise in appearance may not be acceptable to you.

As a way of avoiding a disappointing surprise, if the issue of cosmetics is a major consideration for you, ask questions about the expected esthetic outcome of your case before you decide on a treatment approach.

vi) Is having surgery a problem for you?

Placing dental implants is a surgical procedure whereas having root canal treatment is not (conventional treatment involves performing the work through an opening created in the tooth). Patients who have a fear of surgery may feel more comfortable with the approach of "saving" their tooth.

vii) Lifestyle considerations.

With both procedures, questions should be asked and answered about issues that may disrupt the person's normal lifestyle.

This might include issues such as the expected level of post-procedure discomfort or how post-op numbness, swelling, oral dressings, etc... might affect eating, speaking, appearance, etc...

c) What time frame is needed to complete treatment?

A patient's choice of implant vs. root canal might be swayed by the total amount of time (procedure and healing) that each procedure requires.

Blicher (2008) cites a 2001 survey that reported that:

  • Performing root canal treatment and then placing a dental crown typically requires 4.5 hours of appointment time, broken up into six visits, over a time span of three months.
  • Restoring a tooth's space with a dental implant typically takes 5.5 hours of appointment time, divided among ten visits, over a time span of 9.5 months.

So while the total amount of procedure time is similar for both, the time span over which it takes to complete treatment is roughly three times longer with implants.

Your mileage may vary.

Only your dentist is in a position to know what time frame will be needed for your case. For example, some treatment plans will require additional procedures.

  • Root canal cases - If the tooth is badly broken down (portions of it don't even rise above the gum line), crown lengthening may be indicated. Or, if the tooth has complications associated with periodontal disease, gum surgery will be required.

    With either procedure, additional weeks of healing time will be needed (6 or more).

  • Implant cases - If the quantity or quality of the gum tissue or bone in the region of the implant site is found to be deficient, some type of surgical procedure (augmentation, grafting) will be needed.

    Afterward, some additional months of healing is usually required.

d) Do you grind your teeth?

A habit of tooth clenching or grinding (referred to as bruxism by dentists) may complicate the placement or longevity of dental implants. If this activity can't be controlled, root canal treatment may make the better choice.

e) Medical considerations.

Health issues can affect the outcome of implant therapy. For example, root canal treatment may make the more predictable choice for patients who have uncontrolled (or poorly controlled) diabetes or are smokers. (More details.)

f) Treatment costs.

We've chosen to explore the issue of relative cost and cost effectiveness for root canal therapy vs. implant placement separately. You can find this discussion on this page.

Traditionally dental insurance policies have been more likely to provide benefits for root canal treatment (and crown placement) as opposed to dental implants. Where both are actually covered, the level of benefits paid for each frequently differs. Any of these discrepancies may make choosing one procedure over the other quite easy.



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