Effects of Endodontic Perforations on Tooth Retention and Treatment Costs: A Cost-Effectiveness Analysis

Perforations are complications that may occur during root canal treatment (RCT), requiring complex management if the tooth is to be retained. The influence of perforations and their management on long-term tooth retention and treatment costs remains unclear.

Here, we evaluate endodontic perforations and resulting or alternative treatments for their cost-effectiveness.

A Markov model was developed to follow a molar with a perforation occurring during RCT in an initially 25-year-old patient. The perforation was either managed by repair or tooth extraction with subsequent implant placement. The absence of a perforation served as a control. Our health outcome was the retention time of the tooth or implant. Tooth or implant costs, as well as costs for treatments during follow-up were drawn from public and private fee item catalogues (BEMA and GOZ) in Germany. Costs were calculated in euros (EUR) in the year 2025 and discounted at an annual rate of 3%. Transition probabilities were drawn from systematic reviews.

The cumulative retention time after RCT without perforation was 52.9 years at cumulative lifetime costs of 2000.78 EUR. Perforation repair resulted in a longer retention time of 49.4 years but was also more costly (3485.94 EUR) compared to extraction and implant placement, which yielded a retention time of 44.0 years at a cost of 2813.46 EUR. In the first 13 years after treatment, perforation repair dominated extraction and implant placement, with lower costs and higher effectiveness, because initially perforation repair was less expensive.

Perforation repair increases tooth retention time and comes with only limited or no additional costs depending on the age group. Perforations are associated with significant treatment needs and costs, and endodontic therapy should focus on avoiding them, likely justifying additional efforts if needed to do so.