“Can’t you just pull it?” It’s one of the most common questions we hear once a root canal comes up, usually about a back molar, and usually because of the cost, the time, or plain dread. It’s a fair question, and it deserves a real answer rather than a reflex in either direction.
The short answer: if the tooth can be predictably saved, save it. If it can’t, take it out and plan what goes in the space before it comes out. Over the long run, a root canal tooth and an implant last about the same, so the tooth itself decides most of this, along with time, cost and what matters to you.
What decides whether a tooth is worth saving
A root canal treats the inside of the tooth. Whether the tooth is worth that treatment depends on what’s left of the outside, and on what’s holding it in. These are the questions that matter:
- Is there enough tooth left to rebuild? A back tooth that’s had a root canal needs a crown, and the crown needs sound tooth to grip, ideally a collar of about 1.5 to 2 mm above the gum. When decay or a fracture has taken that away and it can’t be recreated, the outlook gets poor.
- Where is the crack? A crack that stays in the crown can often be treated. A vertical root fracture, where the root itself has split lengthwise, can’t be saved, and that tooth comes out. A crack that runs deep below the gum lowers the odds too.
- Is the bone and gum around it healthy? A tooth with deep pockets, loose from gum disease, or with bone lost between its roots is a weaker candidate, however good the root canal is.
- What does the endodontist think? An endodontist does all of our root canals, and they make their own call. Once in a while they decide a tooth can’t be reliably saved, and we’d much rather know that before treatment than after.
Juloski J, et al. Ferrule effect: a literature review. J Endod. 2012;38(1):11-19. McGuire MK, Nunn ME. Prognosis versus actual outcome. III. The effectiveness of clinical parameters in accurately predicting tooth survival. J Periodontol. 1996;67(7):666-674.
How long each one lasts
Both paths do well, and the research doesn’t crown a winner.
- A tooth after a root canal: pooled studies put survival at roughly 86% to 93% over two to ten years. In insurance records covering almost 1.5 million root canal teeth in the US, 97% were still in the mouth eight years later.
- A single implant: about 95% are still in place at ten years.
- Side by side: reviews comparing the two found similar long-term survival, and concluded that the choice should rest on other things.
Two details are worth knowing. Survival isn’t the same as perfect healing: a root canal tooth can stay in the mouth for years while still needing to be watched. And implants aren’t maintenance-free. In one comparison, implants needed further treatment after placement far more often than root canal teeth did, 17.9% against 3.6%, and an inflammation around implants called peri-implantitis affects about one patient in five.
Ng YL, et al. Tooth survival following non-surgical root canal treatment: a systematic review of the literature. Int Endod J. 2010;43(3):171-189. 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. Jung RE, et al. Clin Oral Implants Res. 2012;23 Suppl 6:2-21. Torabinejad M, et al. J Prosthet Dent. 2007;98(4):285-311. Iqbal MK, Kim S. Int J Oral Maxillofac Implants. 2007;22 Suppl:96-116. Doyle SL, et al. J Endod. 2006;32(9):822-827. Lee CT, et al. J Dent. 2017;62:1-12.
The crown decides as much as the root canal
On a back tooth, the root canal is only half the job. In one study, back teeth that never got a crown were lost at about six times the rate of those that did, and in the large insurance study most of the root canal teeth that ended up pulled had never been fully covered. That’s why we plan the crown before the root canal starts. Why the crown shouldn’t wait.
Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent. 2002;87(3):256-263.
How long until you have a finished tooth
Saving the tooth is the faster road: the root canal, then a crown, usually within weeks. Taking it out and replacing it with an implant is much slower. The socket heals, often after a bone graft, the implant is placed, and then it has to fuse to the bone before the final tooth goes on. From the tooth coming out to a finished tooth going in is usually most of a year. Why the implant timeline runs that long.
What if you just pull it and leave the space?
For a back molar, that can be a reasonable choice. A bite that ends at the premolars often holds up well, and we’ll tell you if leaving the space makes sense in your case. But it isn’t a free choice, and it’s worth knowing what happens:
- The bone shrinks. The ridge that held the tooth narrows fastest in the first three to six months, which is why a graft at the time of extraction matters if an implant might come later.
- The tooth opposite drifts. With nothing to bite against, the upper or lower tooth across from the gap tends to grow down or up into the space. In one study, 83% of back teeth with no opposing tooth had done so.
- The neighbors tip. The teeth beside the gap can lean into it, which opens spaces that trap food.
None of that happens overnight, and none of it hurts, which is why it gets put off. But it’s easier to plan for at the start than to fix years later.
Tan WL, et al. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res. 2012;23 Suppl 5:1-21. Craddock HL, Youngson CC. A study of the incidence of overeruption and occlusal interferences in unopposed posterior teeth. Br Dent J. 2004;196(6):341-348.
What about cost?
Pulling a tooth is the cheapest option today. Whether it stays the cheapest depends on what you do with the space afterward, because replacing a tooth later usually costs more than saving it would have. A root canal and the crown that follows are one sequence with a real combined cost, and we’d rather you see the whole number before deciding than discover it in pieces. How insurance handles a root canal and crown.
One study that compared the options for a back molar whose first root canal had failed found that saving it, by redoing the root canal or with surgery at the root tip, was more cost-effective than a bridge or an implant. That study used national fees from 2009, so treat it as direction rather than a price list.
Kim SG, Solomon C. Cost-effectiveness of endodontic molar retreatment compared with fixed partial dentures and single-tooth implant alternatives. J Endod. 2011;37(3):321-325.
If a root canal doesn’t work
A failed root canal doesn’t automatically mean the tooth comes out. An endodontist can often redo it, or treat the root tip directly with microsurgery, and both have good track records: in reviews, redone root canals healed in about 83% of cases at four to six years, and modern microsurgery succeeded in about 94%. Whether that’s worth doing, or whether extraction is the better call, is decided with the images in front of you. What happens when a root canal doesn’t heal.
Torabinejad M, et al. Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review. J Endod. 2009;35(7):930-937. Setzer FC, et al. Outcome of endodontic surgery: a meta-analysis of the literature, part 1. J Endod. 2010;36(11):1757-1765.
Why we lean toward saving the tooth
An implant is the best replacement we have, and we recommend them often. But it isn’t the same as the tooth it replaces. Your own tooth sits in a ligament packed with sensors, which is what lets you feel a popcorn shell or a filling that’s a hair too tall. An implant fuses straight to bone and doesn’t have that. So when a tooth can be predictably saved, keeping it keeps something no replacement fully matches, and it keeps you out of most of a year of healing.
When a tooth is borderline, it usually deserves a serious attempt first. Some of those teeth give years of good service, and some don’t, and nobody can reliably tell in advance which one yours will be.
That said, this is your decision. Some patients would rather go straight to an implant and be finished, and that’s a legitimate choice. What matters is that it’s made knowing what’s being traded.
How it works here
We diagnose the tooth, check the bite and the bone, and plan the whole sequence before anything starts. An endodontist does the root canal. If the tooth comes out instead, it’s usually a surgeon we work with who removes it, grafting the socket if an implant is likely, and we plan the replacement with them from the tooth side. Either way, the crown, bridge or implant tooth at the end is ours.
Where to start
If you’ve been told you need a root canal, or that a tooth should come out, and you’re weighing the two, call 702-734-0776. We’ll look at the tooth and give you a straight answer about whether it’s worth saving. Signs you may need a root canal.
General education, and not a substitute for an exam.