From Tooth Retention Through Root Canal Treatment to Extraction and Replacement

Initial nonsurgical root canal treatment (NSRCT) is highly successful, is appreciated by patients, relieves pain, and is cost-effective. Results from systematic reviews and studies with very large sample sizes show very high tooth survival rates following NSRCT. Very few patient-associated factors decrease the prognosis for healing after NSRCT. The vast majority of cases will heal following initial NSRCT; the small minority that do not heal are generally best addressed by nonsurgical retreatment. Nonsurgical retreatment is effective and conservative, addressing bacteria remaining within the root canal system. Healing rates increase over time following nonsurgical retreatment. The very small proportion of cases that do not heal after nonsurgical retreatment are best addressed by modern apical microsurgery. Additional case-specific surgical options should be considered before extraction. Intentional replantation remains a viable alternative to extraction. Autotransplantation has a place, particularly in growing patients with an appropriate donor tooth. Root amputation is effective when disease is localized to a single root where adequate remaining tooth structure and periodontal support will remain. Valid reasons to extract and replace an unhealed NSRCT tooth include lack of remaining tooth structure, high caries risk, or high periodontal risk. Not all extracted teeth need to be replaced, but when replacement is indicated, the single-tooth implant is preferred. Single-tooth implants have higher survival rates, but the natural state has intrinsic value. Comprehensive case assessment, evaluation of all endodontic options, and risk assessment for caries and periodontal disease are always necessary when choosing the optimal treatment for a patient when initial root canal treatment has failed to heal.