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How do you decide between a root canal vs extraction for your patients? I have witnessed so much incredible endodontic healing in my career that I am beginning to think that teeth have nine lives.
Unfortunately, so many dentists don’t see what I see.
What makes us believe that a tooth is toast? Why don’t we give teeth a chance and explore alternatives to tooth extraction?
Is it because, as providers, we are afraid to try? Are we worried that we could be wrong about the viability of a tooth with endodontic treatment, which could lead to an angry patient, a refund, or a bad review?
I would honestly love to hear from you about what holds you back when it comes to when to extract a tooth versus when to perform a root canal. What prevents you from recommending endodontic treatment more often? I promise I’m not going to look down on you or chastise you; I genuinely want to know, so that I can address dentists’ real-life concerns.
In the meantime, I want to share a very important tooth story with you. It may be a little heroic when it comes to choosing a root canal vs extraction, but I’m not going to apologize for that, because it’s all about what’s in the best interest of the patient.
Tooth Story: It Started with Pain
When this patient arrived in my practice, he was in a lot of pain. I considered him an emergency patient, because he’d been at level 8 pain for several days, and he was starting to have pain upon biting.
As we know, a great treatment starts with a great diagnosis, so I started my investigation. I took a periapical radiograph of the affected side. This is what it showed.
The teeth have no restorations, but I can clearly see that there is some thickening of the periodontal ligament of both the mesial and distal roots of #30. He had normal probings, except there was a 6mm probing on the DL line angle. The tooth was tender to percussion (++), there was some pain to biting on the bite stick, and there was no response to cold.
So, the diagnosis of this tooth was a Necrotic Pulp and Symptomatic Apical Periodontitis.
Root Canal vs Extraction – Best Course of Action?
The diagnosis is simple in this case, but the treatment plan is not.
We have to remember to ask ourselves, “What is the etiology?” Well, in endo, it’s always bacteria. But there is no decay, so how did the bugs get inside the tooth to infect the nerve?
The clue here is to think outside the box. When you don’t see obvious decay or a broken tooth, then you must think the tooth is cracked. Why? Well, a crack acts as a doorway for bacteria to get inside the tooth and infect the nerve.
So, when I see a tooth that is symptomatic and has no restorations in it, or even has a shallow restoration, I am going to be looking for a crack inside that tooth.
And the question now becomes, how big is that crack? The answer will determine the treatment plan. What is my recommendation regarding root canal vs extraction?
I always say that we can have all the fancy endodontic technology in the world, but until we believe that we have the power to save teeth most people would consider unsaveable, it won’t impact our outcomes. This is an instance where your belief in endo becomes important. Just because there is a crack should not automatically doom that tooth.
The Importance of Imaging when Exploring Alternatives to Tooth Extraction
In these cases, I like to start with a CBCT.
Look, I LOVE my CBCT. But I understand that many dentists don’t have access to this powerful imaging technology. Don’t panic if you’re in that camp. I didn’t have one for years, and I was still able to do a lot of endo—and even treat cracked teeth!
However, a CBCT can give you more insight into the problem, so I want to share this specific case with you to help you see another ROI for this technology. If you have been on the fence about investing in cone beam technology, now you have more information to make a good investment decision.
So, why do I take a CBCT first? It’s to save my patient time and money. If I see a ginormous crack in the tooth that can’t be fixed, then I can recommend extraction and prevent them from having to get endodontic treatment that won’t save their non-restorable tooth.
What did I actually find when I took the CBCT? Let’s take a peek.
The axial slice shows that tooth #30 has 3 canals, and that the distal canal is a nice long oval shaped canal.
If I’m able to treat it, that’s huge insight already, before ever having to numb the patient and access the tooth.
The coronal slice of the mesial root (below) shows that the mesial canals join. Again, great knowledge to have before going into the tooth!
Let’s look at the coronal slice of the distal root. It shows just how wide that distal canal is from a buccal-lingual direction. Personally, I would instrument it like it was two canals.
Finally, the sagittal view gives me more information that impacts my treatment plan and my conversation with my patient. I can actually see that 6mm probing depth that I got on the disto-lingual line angle.
You can also appreciate this here in the axial (below). Here is the axial slice again in case you didn’t pick up on it from the image above.
See that small elliptical radiolucency next to the distal root in the CBCT image above? This is where the crack is clinically in the tooth. Above, in the sagittal view, you can appreciate the depth of that probing. Note that it does not extend all the way down the root.
To Save or Not to Save?
Thanks to my CBCT, I have more confidence in my approach in the conversation with my patient. But before I go there, I want to give you a chance to reflect.
Would you save this tooth or would you extract this tooth? What are your thoughts on root canal vs extraction in this case?
I know many dentists would extract this tooth. Even as a self-described tooth saver, I had my own reservations.
One of the considerations in your treatment plan is what kind of patient is sitting in front of you. This is your opportunity to have an open and transparent conversation with your patient, so you can jointly make the best decision for their oral health.
Here’s how I like to approach these conversations. I let the patient know there is a crack in their tooth, and that crack could get worse over time just from normal wear and tear. This tooth may not last them the rest of their life, unfortunately. I cannot give them a timeline; it may be one month or it may be ten years.
What I do know is that an implant next year is better than an implant today, because the technology continues to improve by the month. So if they can preserve the tooth even for a little while, it could really help them out in the long run.
I give them a treatment plan which includes all treatment options, the cost of treatment, and the time it takes for me to do the root canal (I also have them consider the crown).
At that point, it is their decision regarding whether or not they want to try to save the tooth or extract their tooth right away.
Some people want to try and save their teeth for as long as possible, and some people want to extract the teeth if there is any chance of failure. That is their personal choice.
As clinicians, it’s on us to understand the type of patient that we are talking to in that moment. We do not need to feel responsible for making their treatment decision. Just be open, honest, and transparent about the possibilities without tying a belief onto it. It’s their mouth, after all!
Proceeding with Endodontic Care as an Alternative to Tooth Extraction
In this case, my patient was interested in saving the tooth, so he wanted me to go ahead and proceed with endodontic care.
When I accessed the tooth, here’s how it looked.
I could see that there was a crack on the distal marginal ridge that traveled down the distal surface into the distal orifice.
So, based on this clinical image, ask yourself: is this tooth saveable or does it need to be extracted? Are there any other strategies we can implement here to see if we can give this tooth the best chance possible?
Let me walk you through my thought process.
I decided to clean and shape the tooth like normal, and then obturate a little differently.
Here is my conefit.
And then my backfill radiograph.
Notice how, in the distal root, I did not bring the gutta percha all the way up to the orifice of the canal?
What I am doing here is leaving space for some MTA. I am going to obturate the coronal third of the canal with some MTA and try to seal that crack internally.
Here is what the postoperative radiograph looks like.
I have used this approach many times, but it took some creative problem-solving to realize that it is a viable pivot in my obturation for certain cases. And just because I’ve successfully done this in the past doesn’t mean it will work this time. Every case is different.
Endo Outside the Box
Sometimes in life, we need to think outside the box. In a case like this, since the crack was not that deep, I felt that using some MTA could be a very viable option. However, only a long-term follow up will give us the answer. When he comes in for his one-year recall, we are going to check that bone loss on the disto-lingual with a new CBCT (and some probings) and see if we were able to stabilize this bone or even get some bone regeneration in the area. Fingers crossed!
This patient is going to his dentist ASAP to put on the crown, instead of waiting the normal 2 weeks, and that’s another shift from normal that we needed to make in this case. I really hope we are able to give this tooth more time.
If you want more confidence with cases like this, you don’t need to be an endodontist—you just need a deeper grasp of endo.
One of my favorite words is “why,” because when we know the why behind endodontics, the etiology, the diagnosis, and more, we can focus on what really matters and make treatment decisions that are in our patients’ best interest.
E-School: Everyday Endo Made Easy is my award-winning endodontic CE online course that can bring you a deeper understanding and greater confidence of endo. Empower yourself to enhance your endodontic knowledge, so you can save more teeth! Enroll in E-School now!