The short answer
If the inside of a tooth is inflamed or infected but the root and surrounding bone are sound, root canal treatment is usually the first choice because it keeps your natural tooth. Extraction is usually suggested when a crack runs below the gumline, the root is badly fractured, bone support is gone, or there is too little tooth left to rebuild. Your dentist decides after an exam and X-rays.
General information, not a diagnosis. Your dentist will examine your mouth before recommending treatment.
Why you are facing this choice
You probably have a tooth that hurts, a crack you can feel with your tongue, or an X-ray that shows decay reaching the center of the tooth. The soft tissue inside, called the pulp, is inflamed or infected, and your body cannot clear that on its own. The two ways to end it are to clean out the inside of the tooth or to remove the tooth.
The AAE, the professional group for dentists with additional training in root canal treatment, puts it simply: when you have a choice between the two, saving the natural tooth is usually the better option. The question is whether you really have that choice. That depends on what is left of the tooth and the bone around it, which is why an exam and X-rays come first.
When root canal treatment is usually the first choice
Pulp becomes inflamed or infected from deep decay, repeated dental work on the same tooth, a faulty crown, a crack or chip, or a blow to the tooth. Left alone, it can lead to an abscess. Root canal treatment removes the inflamed or infected pulp, cleans and disinfects the canals, then fills and seals them.
Afterward the tooth is restored with a crown or a filling and keeps working like any other tooth. With proper care, most treated teeth can last a lifetime, according to the AAE. Read why a treated back tooth usually needs a crown before you decide, because the final restoration is part of the plan, not an extra.
Signs that often point this way include a toothache that lingers after hot or cold is gone, pain when you chew, a pimple-like bump on the gum, or a tooth that has darkened. Not every infected tooth hurts, so a quiet tooth can still need treatment.
When a tooth cannot be saved
Sometimes a root canal is not an option. The AAE says a tooth occasionally cannot be saved because the root is severely fractured, the tooth does not have adequate bone support, or the tooth cannot be restored afterward. In those cases extraction is the healthier path, because an infected tooth that cannot be sealed keeps feeding the infection.
Cracks follow their own rules. A crack that runs from the chewing surface toward the root can often be treated with a root canal and a crown to stop it spreading. A crack that extends below the gumline is no longer treatable, a split tooth cannot be saved intact, and a crack that starts in the root often means extraction. Cracks do not heal, so waiting tends to narrow your options.
Advanced gum disease can loosen a tooth until no restoration will hold. If an earlier root canal has failed, retreatment or endodontic surgery may still save the tooth, and your dentist may refer you to an endodontist for that. The site explains what an endodontist is if the word is new to you.
| Situation | Root canal treatment | Extraction | Why |
|---|---|---|---|
| Deep decay reached the pulp; root and bone sound | Usually the first choice | Only if the tooth cannot be rebuilt | Keeps your natural tooth; restored with a crown or filling |
| Crack from the chewing surface toward the root | Often, with a crown to stop the crack spreading | If the crack runs below the gumline | Cracks do not heal; how deep it goes decides |
| Root severely fractured or tooth split | Rarely; sometimes part of the tooth can be kept | Usually | Not enough sound root to hold a restoration |
| Advanced bone loss around the tooth | Not enough on its own | Often | Even a treated tooth needs bone to stay firm |
| Too little tooth above the gum to rebuild | Possible only if a crown can still be anchored | Often | The restoration, not the root canal, is the limit |
| Earlier root canal, tooth sore again | Retreatment or endodontic surgery may save it | If retreatment is not an option | Ask about a referral to an endodontist |
What happens to the gap after an extraction
For any tooth other than a wisdom tooth, the extraction is only half the decision. Missing teeth can cause other teeth to shift and can affect how you chew, so the gap usually needs to be filled, and that means more visits than saving the tooth would have taken. It is worth asking about the replacement before the tooth comes out, so the two steps are planned together.
On this site, the ways to replace a removed tooth are a bridge or a partial denture. Other options may exist, and your dentist will discuss them with you.
- Bridge: a replacement tooth held by crowns on the teeth on either side of the gap. It stays in place and is cleaned under with floss threaders. See dental bridges.
- Partial denture: replacement teeth on a gum-colored base that clips to remaining teeth and comes out for cleaning. See a partial denture for one missing tooth.
- Nothing, for now: possible for a short time, but neighboring teeth may drift, so ask how long you can safely wait.
Questions to ask before you decide
You are allowed to ask why. The AAE suggests that if a dentist recommends extraction, you ask whether a root canal is an option, and if you are told it is not, ask what rules it out. A clear answer names one of the reasons above.
If the plan is a large one or you feel rushed, read when to get a second opinion. A second dentist can review the same X-rays and may agree; the point is that you understand the choice. The post when is a tooth extraction the right call walks through the practice's own view.
- What exactly is wrong with this tooth, and how do you know?
- Is the root intact and is there enough bone around it?
- If we save it, what restoration will it need and when?
- If we remove it, what will fill the gap and how soon?
- What happens if I wait a month?
When it is an emergency, not a decision
An abscess can spread from the tooth into the surrounding bone and soft tissue. A swollen area of the upper or lower jaw is a very serious symptom, according to MedlinePlus. Swelling with fever, trouble breathing or swallowing, or bleeding that will not stop means the emergency room or 911 first, and the tooth decision comes later.
For a severe toothache without those signs, call a dentist. We offer same-day appointments when possible for patients in pain; see the emergency dentist page for what to do before you arrive. Once the infection is under control, the root canal or extraction question can be answered calmly, with the X-rays in front of you.