There is a conversation I have with referring colleagues quite often, and it goes something like this: a patient presents with a tooth that has been causing problems for some time. The general dental practitioner has been managing it, monitoring it, perhaps deferring a decision about its future. By the time the patient reaches me, the clinical picture has changed. What might have been a retrievable situation six months ago has become a significantly more complicated one, or in some cases, is no longer retrievable at all.
I am not raising this to be critical of general dental practice. The pressures on GDPs are real, and the decisions around dental prognosis are difficult ones. But I do think we, as a profession, have a tendency to drift toward extraction and possible implant as the default when a tooth becomes problematic – and to underestimate how much specialist assessment can change the picture before that decision is made.
The tooth preservation decision is more complex than it looks
Assessing the prognosis of a tooth can be less straightforward at times. It requires a clear view of the periapical status, the integrity of the root canal system, the periodontal condition, the restorative history, and the structural viability of what remains. In general dental practice, without specialist endodontic equipment, some of those elements are difficult to assess with confidence.
What I see regularly is teeth being extracted on the basis of an incomplete clinical picture. The data available when making the decision was not enough for a fully informed one. A periapical radiograph may suggest a failing root canal where CBCT reveals a missed canal that, once treated, would restore the tooth to full function. A tooth appearing to be unrestorable may have sufficient remaining structure to support a new restoration when it comes to a specialist treatment, including deep marginal elevation and crown lengthening procedures.
The implant question
There is another dimension to this topic: the growth of implant dentistry has perhaps changed the way we look at tooth preservation in a way that does not always serve patients well.[i][ii] When extraction and replacement with a dental implant is positioned as a clean, modern solution to a difficult tooth, the natural tooth can come to seem like the problem rather than the asset.
But the evidence consistently supports preserving natural dentition wherever it is clinically viable.[iii] A root-treated tooth with a well-fitting crown, in a healthy periodontium, has a long-term survival rate that compares favourably with dental implants in many patient groups.[iv] The bone, the periodontal ligament, the structural relationship with adjacent teeth – implants do not replicate these. They are replaced, imperfectly, after they have been lost.
Of course, I am not arguing against implants. They are a remarkable treatment modality and they change lives. I am arguing against the reflexive extraction of teeth that have not been given a proper chance to be saved.
When the answer really is extraction
To be clear: there are teeth that cannot and should not be saved. A tooth with a vertical root fracture, in most cases, has no retrievable future.[v] When the remaining structure is insufficient to support a restoration, regardless of what is done endodontically, the tooth is not a candidate for complex treatment. When the periodontal prognosis is hopeless, irrespective of the endodontic status, it stands to reason the tooth should not have significant resources invested in it.
Good specialist assessment does not mean recommending treatment at all costs. It means providing an honest, fully-informed opinion about what is possible and what is not – and giving the patient and the referring clinician information they need to make a considered decision. Sometimes that decision is extraction. But it should be a decision, not a default.
Earlier referrals
The cases I find most satisfying are not necessarily the most complex ones – though those have their own rewards – but the cases where a patient has been referred before the situation has deteriorated, where specialist endodontic intervention changes the long-term outlook for a tooth that a patient wants to keep. Earlier referral, even for a second opinion on prognosis, will consistently produce better outcomes than deferred referral once a tooth has become significantly compromised.
EndoCare, led by myself and my colleagues at our Harley Street and Richmond practices, provides specialist endodontic assessment and treatment with access to CBCT imaging, high-magnification operating microscopes, and the clinical experience to give referring practitioners and their patients a clear, honest prognosis. Weekend appointments are available to support flexible referral pathways.
We all know the natural tooth is worth fighting for. In my experience, it is worth fighting for earlier, and more often, than current referral patterns tend to reflect.
For further information about the endodontic referral services available from EndoCare, please call 020 7224 0999 or visit the NEW website www.endocare.co.uk
Author: Dr Michael Sultan, EndoCare
[i] Preserve or extract? Ethical choices in tooth conservation versus implant trends – Oral Health Group. Oral Health Group. Published August 7, 2025. Accessed May 28, 2026. https://www.oralhealthgroup.com/features/preserve-or-extract-ethical-choices-in-tooth-conservation-versus-implant-trends/
[ii] Sartoretto SC, Shibli JA, Javid K, et al. Comparing the Long-Term Success Rates of Tooth Preservation and Dental Implants: A Critical Review. J Funct Biomater. 2023;14(3):142. Published 2023 Mar 3. doi:10.3390/jfb14030142
[iii] Singh B. Maintain a natural tooth or place an implant? “Decision should be patient centered”. J Indian Soc Periodontol. 2025;29(1):1-2. doi:10.4103/jisp.jisp_155_25
[iv] Setzer FC, Kim S. Comparison of long-term survival of implants and endodontically treated teeth. J Dent Res. 2014;93(1):19-26. doi:10.1177/0022034513504782
[v] Khasnis SA, Kidiyoor KH, Patil AB, Kenganal SB. Vertical root fractures and their management. J Conserv Dent. 2014;17(2):103-110. doi:10.4103/0972-0707.128034
