Objective: To compare oral health-related quality of life (OHRQoL) between patients undergoing root canal treatment (RCT) and tooth extraction in Malaysia. Methods: A cross-sectional study was conducted among 484 adult patients (243 RCT, 241 extrac-tion) attending public restorative dental clinics in Selangor and Kuala Lumpur. Par-ticipants completed the validated 14-item Malaysian Oral Health Impact Profile (S-OHIP(M)). Independent t-tests and chi-square tests were applied (p < 0.05). Results: The RCT group reported significantly lower mean OHIP-14 scores (12.9 ± 8.4) com-pared to the extraction group (18.5 ± 10.5), indicating better OHRQoL. Across all OHIP-14 domains, RCT patients experienced fewer functional limitations, less pain, reduced psychological discomfort, and lower social handicap. Sociodemographic dif-ferences were observed in age, gender, and education, but not ethnicity. Conclusion: RCT is associated with better OHRQoL outcomes than extraction, supporting its role as a tooth-preserving, cost-effective option. Findings highlight the importance of inte-grating patient-centred outcomes into oral health policy and clinical decision-making.