Each clinical situation is unique and different. In cases where a tooth has been previously restored, differences in treatment recommendation tends to be greater. There is a need to develop objective criteria for treatment of teeth with previous restorations. Both root canal therapy as well as implant treatment have benefits and risks, they also complement each other as treatment options.

Dental implants are a useful alternative in tooth replacement that have poor prognosis. Implant placement involves surgical-induced pain/inflammation and is about twice expensive as nonsurgical endodontic therapies, associated with more post-treatment procedures and provide no better survival rates compared to restored endodontically treated tooth. On the basis of these considerations, routine recommendations of single-tooth implants should not be recommended that could first be saved by endodontic treatment. A compromised tooth must be viewed with a total restorative approach unless clinically the tooth is deemed to having ‘end-stage failure’.

Indications for dental implants start to be conflicting when compared to indications for endodontic therapy, then there is a need for the development of specific guidelines to provide the patient with sufficient information to select the optimal procedure for their particular treatment option. The optimal treatment plan must incorporate the best available evidence together with specific factors and the patient’s desires and needs. Although it is recognised that clinicians vary in their experience, skills and interests, this should not decide the treatment plan, and referrals to other members for specialised care on a referral basis must also be considered.

Patient as well as clinical factors may determine whether to perform tooth preservation or extraction with an implant-supported restoration. If a tooth is restorable then endodontics is our first choice. If the tooth is un-restorable then the best choice is implant treatment. To save natural teeth as much as possible is still our primary goal, we are trained to preserve natural dentition, it is our ethical responsibility but long-term outcome needs clarity in the literature.

There is no perfect treatment planning guide to help us in the decision making process whether we should consider extracting or saving a compromised tooth. Because of current controversies and contradictory indicators for dental implants and endodontics in compromised teeth, there is definitely a need to establish clearer guidelines pertaining to decision-making and treatment planning. It is the clinicians responsibility to make the final decision by considering all factors in the decision making process, all of the evidence must be considered to make a rational and ethical decision. The ultimate goal of both implants and endodontics is to help and facilitate rehabilitation of the patient’s natural dentition to restore function and aesthetics. It must be remembered that endodontic therapy is intended to retain existing teeth whereas implants are intended to replace missing or lost teeth.

There is a great degree of differences in studies reporting outcome measures and criteria for success.

A review of the literature does not allow for direct comparison of single-tooth implants and restored root canal-treated teeth because of differences in study design as well as content of data collected. Future studies should provide survival data that is recorded in private practice settings because of publication bias in many industry sponsored clinical trials and settings. In-depth evaluation of different treatment modalities should also report on raw data as far as possible.

As current controversy continues even with a plethora of clinical evidence for and against endodontic and implant treatment; “TO SAVE, OR NOT TO SAVE?” – is still the question that beckons!