Endodontic therapy or extraction and tooth replacement with implants? Decision-making criteria – a narrative review

Objective The decision between preserving a compromised tooth through endodontic therapy or replacing it with a dental implant remains a frequent clinical dilemma. This narrative review aims to evaluate the available evidence regarding clinical outcomes, success rates, prognostic factors, and patient-related considerations associated with endodontic treatment and implant therapy to support evidence-based clinical decision-making.

Materials and Methods A comprehensive literature search was performed in electronic databases including PubMed, EMBASE, Wiley Online Library, Cochrane Library, and ScienceDirect up to October 2025. Studies evaluating outcomes of endodontic therapy and dental implant treatment in human subjects were included. A total of 13 studies (including cohort, case-control, cross-sectional, and one randomized controlled trial) were selected. Data extraction focused on study characteristics, interventions, follow-up duration, and clinical and patient-reported outcomes. Risk of bias was assessed using a domain-based approach adapted from the RoB 2 tool, modified to account for the inclusion of predominantly non-randomized studies.

Results Both endodontic therapy and dental implant treatment demonstrate high long-term survival rates when performed under appropriate clinical conditions. Endodontically treated teeth commonly show survival rates exceeding 85–90% over long-term follow-up periods, while implant survival rates typically range from 90% to 97%. However, direct comparison between the two modalities remains challenging due to heterogeneity in study design, follow-up duration, and definitions of success and survival. Biological complications such as peri-implant mucositis and peri-implantitis may affect implants, whereas endodontic therapy may fail due to persistent infection or inadequate restoration.

Conclusions Both treatment modalities represent predictable therapeutic options. Preservation of the natural tooth through endodontic therapy should generally be considered the first approach whenever the prognosis is favorable, while dental implants provide a reliable alternative when tooth preservation is not feasible. Clinical decision-making should integrate biological, restorative, systemic, and patient-related factors.