Save the tooth or replace it? In the Swedish cohort, it depends on the site

One of the most common clinical decisions in general practice is whether to save an endodontically diseased tooth with root canal treatment or extract it and replace it with an implant. This large, register-based cohort study from Sweden set out to compare survival, functional time, and cost between the two strategies under real-world conditions.

Using the Swedish Dental Health Register, the authors identified all adults diagnosed with endodontic disease in 2015-2016 who received either root canal therapy (ENDO, n=10,654) or extraction with implant-supported replacement (IMPLANT, n=5,327), following them until 2023 in propensity-score-matched groups. Survival was analyzed with Kaplan-Meier and Cox regression; functional time was expressed as restricted mean survival time (RMST) truncated at 7 years; and cumulative treatment costs, discounted at 3% annually, fed into incremental cost-effectiveness ratios (ICERs).

At 9 years, survival was 83.4% for root canal-treated teeth versus 97.9% for implants. Mean functional time was 5.8 years for ENDO versus 6.6 years for IMPLANT, at mean cumulative costs of USD 1,243 versus USD 2,667 respectively. The overall ICER was USD 1,874 per additional year of function, ranging from USD 1,352 at maxillary molar sites to USD 4,836 at maxillary anterior sites. Notably, this pattern reversed at mandibular anterior sites, where root canal treatment achieved both higher survival and lower cost than implants.

Clinical relevance: on average, implants outlasted endodontically treated teeth and functioned longer, but at roughly double the cumulative cost — and the advantage was not universal. At mandibular anterior sites specifically, saving the tooth was both the more durable and the cheaper option. For clinicians and patients weighing 'save the tooth or replace it,' this data argues against a one-size-fits-all default and toward a site-specific decision, informed by both expected longevity and cost.