Save the tooth instead of pulling it — when is that still possible?

Modern replacements are good. That is exactly why it is worth being clear about what they do not reproduce.

A natural tooth is not fixed rigidly into the jaw. It hangs in a thin ligament (Wurzelhaut) of elastic fibres that lets it move a fraction of a millimetre under load, cushions the force of chewing, and — this is the part people underestimate — reports back. That ligament is packed with receptors telling your brain how hard you are biting. It is why you can feel a grain of sand in a salad, and why you instinctively stop before you crack a nut on the wrong tooth. An implant is anchored directly in bone and has no such ligament, which is why implant patients often describe a subtly different feedback when chewing.

Keeping the tooth also keeps the bone busy: bone responds to load, and a tooth transmits chewing forces into the jaw through that ligament. Once the tooth is gone, the bone at that site begins to shrink, which is why bone grafting (Knochenaufbau) is sometimes needed later. Keeping a tooth also leaves the neighbours alone — a conventional bridge (Brücke) requires the two adjacent teeth to be ground down for crowns, often healthy teeth that would never otherwise have needed treatment.

None of this makes replacement a poor choice. It makes it a second choice, appropriate when the first is no longer realistic.

“Can it be saved?” sounds like a matter of opinion. In practice a handful of concrete findings decide it, and you are entitled to be shown each of them.

How much sound tooth is left above the gum. The decisive one. A crown needs a continuous collar of healthy tooth substance to grip — dentists call it the ferrule effect, and without it the restoration works like a lever on the root and eventually fractures it. This is why a tooth broken off deep below the gum line is a genuine problem, while a tooth with a large cavity but intact walls is often straightforward.

Whether the root is intact. A vertical fracture running lengthwise down the root cannot be repaired, because bacteria travel along the split and no material seals it. Under a microscope such cracks are often visible directly; sometimes a 3D X-ray (DVT) is what settles the question.

How much bone is holding it. On the X-ray, the bone level around the root is measured, and in the mouth the gum pockets are probed and the tooth’s mobility graded. A tooth with two-thirds of its bone support gone behaves quite differently from one that has lost a quarter.

The proportion of root in bone to crown above it. A long root well anchored in bone tolerates a crown comfortably. A short remaining root carrying a tall restoration is working at a mechanical disadvantage.

Whether the canals can be reached. Calcified, sharply curved or previously blocked canals are the technical limit of what can be cleaned and sealed.

What job the tooth does. A tooth that anchors a denture, closes a gap, or keeps the opposite tooth from drifting is worth more effort than a wisdom tooth (Weisheitszahn) with nothing biting against it.

Most patients know about root canal treatment (Wurzelbehandlung) and assume that is the whole repertoire. It is not. Several of the following are the difference between a tooth that has to go and one that stays.

Root canal treatment, and retreatment of an old one. The starting point where the nerve is inflamed or dead. A tooth that already has a root filling and is causing trouble can very often be retreated rather than removed — dentists call that a revision, and it is a save option in its own right. Root canal revision or extraction? How the decision is made (EN)

Rebuilding the tooth. Where a lot of substance is missing, a post is placed in the root to retain a build-up, and a crown (Krone) is made over it. In our own master dental laboratory (Meisterlabor) that work is done in-house, and digital impressions with Primescan replace the impression tray most people remember unfondly.

Crown lengthening. Where a tooth has broken close to the gum, the gum — and sometimes a small amount of bone — can be recontoured to expose more sound tooth, giving the crown something to hold. This turns a number of apparently hopeless teeth into restorable ones.

Orthodontic extrusion. A more elegant variation: a tooth broken deep below the gum can sometimes be pulled slowly upwards over weeks using gentle orthodontic force, bringing sound tooth structure into reach. It takes time, and it is not suitable for every case, but it saves teeth that would otherwise be extracted.

Root-tip surgery (Wurzelspitzenresektion). Where an infection at the root tip persists despite a technically sound root filling, the tip of the root and the inflamed tissue around it can be removed through a small procedure from the outside, and the canal sealed from below.

Splinting. A tooth loosened by bone loss or an accident can be bonded to its neighbours so the group shares the load while the tissue stabilises.

Removal of a single root. Molars have several roots, and where one is damaged beyond repair but the others are sound, that root can sometimes be removed and the rest of the tooth kept. A specialised solution, not right for everyone — but it exists.

Which of these apply depends entirely on the individual finding, and the assessment is where magnification pays off: a crack, a missed canal or a perforation is often what separates “keep” from “remove”, and none is reliably visible without it.

A save attempt is not always in your interest, and a dentist who says so is doing their job. The clear limits are a root split lengthwise, so little tooth left that nothing can be anchored, bone support largely gone through advanced gum disease (Parodontitis), and canals that cannot be negotiated. A tooth needing an elaborate rescue that would still carry a poor outlook is sometimes better replaced with something predictable, particularly where a plan for the whole mouth depends on it holding. The stages of infection are covered in Can an inflamed tooth be saved? Stages, symptoms and chances (EN).

This is where the German system genuinely surprises people from abroad, so it is worth going through properly. Two different rulebooks apply to the two paths.

The root canal itself. Statutory health insurance (gesetzliche Krankenversicherung, GKV) covers root canal treatment as standard care (Regelversorgung) for front teeth and premolars. For molars the fund pays where the tooth is judged worth keeping under defined criteria — broadly, where treating it preserves a complete row of teeth, closes an existing gap, or prevents a removable denture (Prothese) becoming necessary. Where a molar falls outside those criteria, the fund would finance extraction and replacement instead; you can still choose to have the tooth treated privately.

The refinements are private. Treatment under the microscope, electronic measurement of the root length, flexible instruments for shaping the canals, extended disinfection, retreatment of an existing root filling, and 3D imaging where anatomy is unclear are all private add-ons under the dentists’ fee schedule (GOZ). They are quoted before treatment. Private insurance (private Krankenversicherung, PKV) and supplementary cover (Zahnzusatzversicherung) reimburse a share set by the tariff, depending on the tariff.

The crown on top follows the prosthetics rules. Here your fund pays a fixed subsidy (Festzuschuss) towards standard care, and your bonus booklet (Bonusheft) raises it: 60 % without regular stamps, 70 % after five unbroken years, 75 % after ten, and up to 100 % under the hardship provision (Härtefallregelung) for low incomes.

The extraction is covered by the fund. What follows is not so simple.

An implant (Implantat) is the part expat patients most often misunderstand. The GKV does not pay for the implant itself — the screw and the surgery are private. What the fund does pay is the Festzuschuss for the crown on top, at exactly the same rate it would have paid for standard care without an implant. For a single-tooth gap (finding 2.1), the 2026 figures are:

Against that sits the actual cost. As a general market range in Germany — not our practice’s prices — an implant with its crown, all in, runs roughly 2,100–4,000 €: diagnostics 100–350 €, the surgical stage 1,000–2,000 €, and the crown on the implant 800–2,000 €. Where the bone has already shrunk, a bone graft (Knochenaufbau) adds roughly 500–2,500 €. At our practice the surgical part — the implant itself — starts at 999 €, and a 3D X-ray (DVT) costs 178 €.

Time is part of the cost too. After an implant is placed, the healing phase (Einheilphase) averages 3–6 months before the final crown goes on. A bridge avoids that wait but requires grinding down two neighbouring teeth. A partial denture is the least expensive route and the one most patients like least.

The comparison, then, usually looks like this: keeping a tooth means a root canal, possibly a build-up, and a crown — with the fund contributing to the crown and, in most cases, to the root canal. Replacing it means an extraction the fund covers, followed by a replacement where the fund contributes only the Festzuschuss and the rest is yours. That is why keeping the tooth is normally the cheaper path, often substantially.

A save attempt that fails is not free. If the tooth is treated, crowned and lost two years later, you have paid for the rescue and then pay for the replacement. That risk is real and belongs in the decision — which is precisely why the prognosis should be stated in plain words before you agree, not afterwards. Ask directly: how likely is this to hold, and what would make it fail?

One procedural rule you cannot afford to miss. The treatment and cost plan (Heil- und Kostenplan, HKP) must be submitted to your fund before treatment begins. Start first and the entitlement to the Festzuschuss is lost. How long the fund takes varies from fund to fund, so build that into your planning.

A note on what may change. A draft law (GKV-Beitragssatzstabilisierungsgesetz) that passed cabinet on 29 April 2026 proposes reducing these subsidies to 50/60/65 %, keeping the 100 % hardship rate. It has not passed the Bundestag or Bundesrat and is a proposal under discussion, not current law — today’s figures are the ones above. If you have been putting off a decision for years, it is one more argument for not putting it off further.

Delay rarely changes a tooth’s fate overnight, but it narrows the options steadily. Decay that has reached the nerve keeps going: a cavity confined to the crown may need a filling, while the same cavity six months later may have destroyed the wall a crown would have gripped. Chronic infection at the root tip keeps affecting the surrounding bone. A cracked tooth propagates its crack under chewing load, and there is a point past which the crack reaches the root and the discussion ends.

Once a tooth is out, the clock runs the other way: neighbouring teeth drift into the gap, the opposing tooth grows down towards it, and the bone at the site begins to shrink — which is what turns a straightforward implant into one that needs grafting first. None of this is a reason to panic. It is a reason to have the tooth assessed while there is still a choice to make.

Get seen the same day if swelling spreads towards the eye or into the neck, or if you have difficulty swallowing, opening your mouth or breathing. Outside opening hours that is what the out-of-hours service (Notdienst) exists for.

Two things routinely go wrong for new arrivals, and both are avoidable.

The first is the paperwork order. Anything involving a crown, bridge or denture needs the HKP to reach your fund before treatment starts. Nobody will refund you afterwards for a step taken in the wrong sequence.

The second is the conversation itself. A decision between keeping and replacing a tooth depends on nuance — probabilities, alternatives, what happens if it does not hold — and nuance is the first casualty of a language barrier. English is one of our working languages, so the finding, the options and the figures can all be discussed properly and given to you in writing. For patients in Düsseldorf, Cologne, Bonn or elsewhere in NRW, 20 to 30 minutes to reach a practice where that is straightforward is an ordinary journey: English-Speaking Dentist in NRW.