Endodontic Treatment for Children and Adolescents: Pulpotomy, Apexogenesis, and Immature Permanent Teeth product guide

Endodontic Treatment for Children and Adolescents: Pulpotomy, Apexogenesis, and Immature Permanent Teeth

When a parent hears that their child may need a "root canal," the reaction is almost universally one of alarm. The phrase conjures images of lengthy adult procedures, significant discomfort, and irreversible intervention. But endodontic treatment for children and adolescents is a fundamentally different discipline - one governed by developmental biology, the natural lifecycle of primary teeth, and the critical imperative to protect a child's permanent dentition as it matures.

The procedures used in paediatric and adolescent endodontics - pulpotomy, pulpectomy, apexogenesis, and apexification - are not simply scaled-down versions of adult root canal therapy. They are biologically distinct interventions, each with its own clinical indications, materials, technique requirements, and long-term implications for tooth development. This is precisely why cases involving children and adolescents with compromised pulps require specialist assessment and, in many situations, specialist management.

This guide explains each procedure in plain language, presents the evidence supporting current clinical approaches, and addresses the questions parents most commonly ask about endodontic care for young patients.

Why Children's Teeth Require a Different Endodontic Approach

The Biological Difference Between Primary and Permanent Dentitions

Primary (baby) teeth are not simply smaller permanent teeth. They have thinner enamel and dentine, larger pulp chambers relative to crown size, and roots that undergo physiological resorption as the permanent successor erupts beneath them. These anatomical realities change the calculus of treatment entirely.

In primary teeth, the goal of endodontic treatment is almost never long-term tooth retention in the same way it is for permanent teeth. Instead, the clinical objective is to maintain the tooth in a healthy, infection-free state until natural exfoliation, thereby preserving space for the erupting permanent tooth and protecting the underlying tooth bud from bacterial contamination.

In immature permanent teeth - those that have erupted but whose roots have not yet fully formed - the stakes are higher still. In the absence of a vital pulp, dentin deposition is arrested. Losing pulp vitality in an immature permanent tooth can halt root development, leaving the tooth with thin, fragile dentinal walls and an open apex that makes conventional root canal treatment technically demanding and structurally compromised. The young pulpless tooth frequently has thin, fragile walls, which makes it difficult to adequately clean and to obtain the necessary apical seal.

How Common Are These Presentations in Children?

Endodontic intervention in children arises from two primary causes: dental caries and traumatic dental injury (TDI).

Dental trauma is common in all age groups, although epidemiologically it is more common in children, with studies indicating that 15% of preschoolers and 20–25% of school-age children experience it.

Traumatic dental injuries affect about 20–30% of permanent dentition worldwide, and nearly 80% of dental trauma occurs under the age of 20 years, making childhood and adolescence highly vulnerable periods.

The age period from 7 to 10 years is especially vulnerable because at that age, the root development of the permanent incisors is still incomplete. This means a trauma event at precisely the wrong developmental window can leave a child with an immature permanent tooth that requires specialist endodontic management for years.

According to Frances M. Andreasen et al., 30% of pulp necrosis in immature permanent teeth is a consequence of dental trauma.

Pulpotomy for Primary Teeth: What It Is and When It Is Used

Definition and Clinical Indication

A pulpotomy is the removal of the coronal (crown) portion of the dental pulp while leaving the healthy radicular (root) pulp intact. It is the most commonly performed endodontic procedure in primary teeth.

The main indications for pulpotomy are teeth with extensive caries, no spontaneous pain, and no evidence of radicular pathology. The procedure is appropriate when decay has reached - or is very close to - the pulp, but infection has not yet spread into the root canals. The high clinical and radiographical success rates of pulpotomy for primary teeth with irreversible pulpitis can be attributed to the fact that not all cariously exposed pulps were completely infected, with inflammation and microbial invasion possibly confined to the coronal pulp.

The Pulpotomy Procedure: Step by Step

1. Diagnosis and radiographic assessment - periapical X-rays confirm the absence of radicular pathology (furcation involvement, internal resorption, or periapical lesion)
2. Local anaesthesia - profound anaesthesia is achieved before any tissue removal
3. Caries removal and access - all decay is excavated and the pulp chamber is accessed
4. Coronal pulp amputation - the infected coronal pulp tissue is removed with a sterile bur or sharp excavator
5. Haemostasis - bleeding from the radicular pulp stumps is controlled, typically with a sodium hypochlorite-moistened cotton pellet
6. Pulpotomy medicament placement - a biocompatible material is placed over the remaining pulp stumps
7. Restoration - the tooth is restored, ideally with a stainless-steel crown (SSC)

What Materials Are Used?

The choice of pulpotomy medicament has evolved significantly over the past two decades. Formocresol, the historical standard, has been largely replaced due to concerns about its cytotoxicity. Pulpotomy medicaments and techniques, except calcium hydroxide, had success rates of more than 80% for all domains and time periods, and most comparisons revealed no differences in the clinical, radiographic, or overall success rates.

Mineral trioxide aggregate (MTA), however, was found to be better than calcium hydroxide and formocresol in several respects.

The most effective long-term restoration for pulpotomised primary teeth has been shown to be a stainless-steel crown (SSC) due to its good sealing and full coverage, with higher success rates using an SSC reported when compared with IRM, RMGI, or composite restorations.

What Does the Evidence Say About Pulpotomy Success?

The clinical evidence for pulpotomy in primary teeth is robust. A 2024 systematic review and meta-analysis published in Children (MDPI) found that pulpotomy-treated teeth exhibited high clinical and radiographical success rates at the 6-month (overall success: 97.2%) and 12-month (overall success: 94.4%) follow-up periods.

A separate meta-analysis examining Biodentine (a calcium silicate-based material) found that primary teeth submitted to pulpotomy showed a slightly reduced success rate, with 98.90% success at three months and 92.82% at 24 months.

One retrospective study cited in PMC found higher clinical success rates for pulpotomy (99%) than pulpectomy (88%) in primary molars with carious pulp exposures or symptomatic irreversible pulpitis over an 18-month period.

These figures make pulpotomy one of the most evidence-supported procedures in paediatric dentistry - provided the correct clinical selection criteria are applied.

Pulpectomy for Primary Teeth: When Pulpotomy Is Not Enough

When infection has spread beyond the coronal pulp into the root canals of a primary tooth, a pulpectomy (complete pulp removal) is indicated. This is the closest analogue to a conventional adult root canal in the primary dentition, though the technique differs significantly due to the resorbing nature of primary tooth roots.

Root filling materials for primary teeth must be resorbable - they must resorb at roughly the same rate as the physiological root resorption that occurs as the permanent successor erupts. Non-resorbable materials used in adult root canal treatment are contraindicated in primary teeth because they can impede the eruption of the permanent tooth.

There is evidence to use calcium hydroxide, zinc oxide eugenol paste, or iodoform-based pastes as root filling materials for non-vital primary molars.

Stainless-steel crowns are recommended as definitive restorations after both endodontic treatments.

Immature Permanent Teeth: Apexogenesis vs. Apexification

This is where paediatric endodontics becomes most clinically complex - and where specialist involvement is most critical. When a permanent tooth erupts, its root continues developing for approximately two to three years. Post-eruption, root development and apex closure are completed within three years, and the tooth is susceptible to various accidents and aggressions throughout this period.

Certain teeth do not have a closed root tip, resulting in what is called an "open apex." These teeth are not fully developed and still need time to grow and gain strength. Open apex teeth cannot be treated with conventional root canals, as the tip of the root cannot be sealed in the same way.

The two principal treatment pathways for immature permanent teeth are apexogenesis (when the pulp is still vital) and apexification (when the pulp is necrotic).

Apexogenesis: Preserving Vitality to Complete Root Development

The treatment of vital pulp in an immature tooth to permit continued root growth and apical closure is called apexogenesis. It is the preferred approach whenever viable pulp tissue remains, because maintenance of pulp vitality by using apexogenesis will allow continued root development along the entire root length.

The dental pulp in young patients is more cellular and able to recover from injuries. This biological advantage means that even teeth with significant pulp exposure - from trauma or deep caries - can often be treated conservatively if intervention occurs promptly.

Depending on the extent of inflammation, pulp capping, shallow pulpotomy, or conventional pulpotomy may be indicated.

The apexogenesis procedure:

1. Clinical and radiographic assessment to confirm pulp vitality
2. Local anaesthesia and rubber dam isolation
3. Removal of the compromised coronal pulp tissue (to a depth determined by the extent of inflammation)
4. Haemostasis confirmation - bleeding that can be controlled indicates a healthy radicular pulp
5. Placement of a biocompatible pulp-capping material (MTA or calcium silicate-based bioceramic) directly over the remaining pulp
6. Coronal seal with a bacteria-tight restoration

This allows the pulp to heal, preserving its vitality and encouraging the tooth to mature and strengthen naturally. If the pulp heals, no additional endodontic treatment is necessary.

Apexification: Managing Necrotic Pulp in an Immature Tooth

When the pulp of an immature permanent tooth has become necrotic - most commonly following trauma or untreated deep decay - apexogenesis is no longer possible. Apexification is a necrotic pulp procedure which debrides, disinfects, and obturates the root canal of immature teeth. The obturation of the root canal with calcium hydroxide or mineral trioxide aggregate (MTA) will induce an apical calcified barrier to help save the tooth.

There are two primary approaches to apexification:

The advantages of apexification using an MTA plug are reduced treatment time and a more predictable barrier formation. The shortcoming, similar to calcium hydroxide therapy, is that placement of an apical plug does not account for continued root development along the entire root length.

The results of several studies show that MTA plugs are effective in treating immature permanent teeth with necrotic pulps, with the advantages of apexification with an MTA plug being reduced treatment time - one-visit apexification - and more predictable barrier formation.

Regenerative Endodontics: The Emerging Third Option

In cases where the pulp is necrotic but the tooth is very immature with extremely thin dentinal walls, regenerative endodontic procedures (REP) represent an emerging alternative. Regenerative endodontics has the unique potential advantage of being able to continue the root development in immature permanent teeth, thereby potentially saving the teeth for the lifetime of the patient.

However, case selection is critical. Very immature teeth at an early stage of development, with thin and weak dentinal walls, are more prone to fracture, and these fragile teeth would most benefit from regenerative endodontic treatment to continue dentinogenesis to strengthen the teeth. Conversely, conventional endodontic root canal treatment, Cvek partial pulpotomy, apexogenesis, and apexification should always be provided when these treatments are more likely to benefit the patient because they can be more successful than regenerative endodontics.

This nuanced decision-making - selecting between apexogenesis, apexification, and regenerative endodontics - is one of the most clinically demanding areas of endodontics and is a core reason why specialist assessment is recommended for all immature permanent teeth requiring endodontic intervention.

Addressing Parent Concerns: Anaesthesia, Behaviour, and Safety

Is Local Anaesthesia Safe for Children?

This is among the most common concerns parents raise. The answer is yes - local anaesthesia is both safe and essential for paediatric endodontic procedures. Local anaesthetic agents used during paediatric dentistry include lidocaine and prilocaine, which are commonly supplied in cartridges containing 2.2 ml. These drugs are usually administered by the dental surgeon and used in combination with vasoconstrictor agents such as epinephrine or felypressin to improve haemostasis.

An important anatomical consideration: the techniques for achieving local anaesthesia in children are similar to those performed in adults; however, the reduced bone density of the maxilla and mandible in children leads to a more rapid diffusion and absorption of local anaesthetic solution. This means anaesthesia is typically achieved faster and with smaller volumes in children than in adults.

What If My Child Is Anxious or Uncooperative?

Behaviour management is a core competency in paediatric endodontic care. As per the American Academy of Pediatric Dentistry (AAPD) and the American Association of Pediatrics (AAP), the objectives of sedation encompass: guarding the patient's safety and welfare; minimising physical discomfort and pain; controlling anxiety, minimising psychological trauma, and maximising the potential for amnesia; modifying behaviour to allow safe completion of the procedure; and returning the patient to a safe discharge state.

For most children over the age of ten, endodontic procedures can be completed comfortably under local anaesthesia alone, with appropriate communication and non-pharmacological behaviour management strategies. Children over the age of 10 years are more likely to have the ability to think abstractly and respond appropriately to explanations. Children in this age group may therefore be able to cooperate with dental treatment performed under local anaesthesia, with or without sedation.

Younger children or those with significant dental anxiety may benefit from relative analgesia (nitrous oxide/oxygen), oral sedation, or in some cases, treatment under general anaesthesia. Communication with parents or legal guardians is crucial for effective guidance of a child's behaviour during dental procedures. Maintaining open communication with parents can help ensure the child's safety and comfort during the procedure, and it can also help alleviate any anxiety or concerns that the parents may have.

What Are the Long-Term Implications for My Child's Teeth?

For primary teeth, successful pulpotomy or pulpectomy preserves the tooth until natural exfoliation, maintaining arch space and protecting the underlying permanent tooth bud from infection. An infected primary tooth left untreated can cause damage to the developing permanent tooth beneath it - including enamel defects, displacement, or disruption of eruption timing.

For immature permanent teeth, the long-term implications depend heavily on the treatment pathway chosen and how early intervention occurs. The core objective in managing immature permanent teeth is to preserve pulp vitality to support continuous root development, as pulp viability is the physiological prerequisite for guiding root maturation.

A tooth that successfully undergoes apexogenesis and completes root development has a long-term prognosis comparable to any other endodontically sound permanent tooth. A tooth that requires apexification, while successfully treated, will have a shorter root with thinner walls than one that completed natural development - making appropriate coronal restoration and long-term monitoring critical.

Why These Cases Require Specialist Endodontic Management

Paediatric and adolescent endodontic cases are not simply simpler versions of adult cases. They are more complex in several specific ways:

• Diagnostic complexity: Distinguishing between reversible and irreversible pulpitis in a primary tooth, or between a healthy open apex and a pathological periapical lesion in an immature permanent tooth, requires clinical experience and often advanced imaging. An immature tooth with a healthy pulp is typically surrounded by a radiolucent region where the open apex is still forming. It may be difficult to differentiate between this finding and a pathologic radiolucency resulting from a necrotic pulp.

• Developmental consequences: A clinical error in a child's mouth - missed infection, inappropriate material, or premature extraction - can affect the developing permanent dentition for a lifetime.

• Technique sensitivity: Apexification with MTA requires precise placement to avoid extrusion of material beyond the open apex. An accurate determination of root length is required to ensure complete canal débridement and to confine treatment materials to the canal space to avoid damaging the very valuable remnants of the Hertwig epithelial root sheath. Generally, electronic apex locators are not accurate in teeth with wide-open apices.

• Radiographic interpretation: Cone-beam computed tomography (CBCT) or digital volume tomography overcomes the drawbacks of two-dimensional radiography in these cases, providing three-dimensional assessment of root development stage, periapical status, and canal morphology. (See our guide on Root Canal Technology at Smile Solutions: Cone Beam CT, Rotary Instrumentation, and Dental Microscopes for more detail on how CBCT improves diagnostic accuracy.)

• Material selection: The choice between calcium hydroxide, MTA, Biodentine, and bioceramic materials for pulpotomy or apexification must be made on the basis of current evidence, case-specific factors, and specialist experience.

At Smile Solutions, our board-registered specialist endodontists are specifically trained and equipped to manage these cases. The Dental Board of Australia's specialist registration in endodontics requires completion of an accredited postgraduate program that encompasses the full breadth of these paediatric presentations - not just adult root canal therapy. (See our guide on Board-Registered Specialist Endodontists vs. General Dentists: Who Should Perform Your Root Canal? for a detailed comparison of training pathways and clinical scope.)

Quick Reference: Choosing the Right Procedure

Key Takeaways

• Pulpotomy in primary teeth is highly evidence-supported, with systematic reviews reporting overall success rates of 94–97% at 12 months. MTA and calcium silicate-based materials (Biodentine) are the current materials of choice over formocresol.
• Immature permanent teeth cannot be treated with conventional root canal techniques because their open apices cannot be sealed conventionally, and their thin dentinal walls are at risk of fracture. Apexogenesis (if the pulp is vital) or apexification (if necrotic) are the appropriate interventions.
• The window for apexogenesis is time-critical: the sooner a traumatised or decayed immature tooth is assessed, the greater the chance of preserving pulp vitality and allowing natural root completion.
• Local anaesthesia is safe and effective in children, with the reduced bone density of the paediatric jaw enabling faster and more complete anaesthetic diffusion than in adults.
• Specialist endodontic assessment is warranted for any child or adolescent with a compromised immature permanent tooth, given the diagnostic complexity, developmental stakes, and technique sensitivity involved.

Conclusion

Endodontic treatment for children and adolescents sits at the intersection of developmental biology, paediatric behaviour management, and specialist clinical technique. Whether the presentation is a carious primary molar requiring pulpotomy, or a traumatised immature incisor requiring apexogenesis, the stakes are uniquely high: the decisions made in these early years can shape a patient's permanent dentition for decades.

The evidence supports conservative, biologically driven approaches - preserving pulp vitality wherever possible, using contemporary biocompatible materials, and restoring teeth appropriately to protect the investment of treatment. What the evidence also supports is that these cases are best managed by clinicians with specialist training in endodontics, not as an afterthought, but as a first principle.

If your child has experienced dental trauma, has been told they may need a root canal on a primary or permanent tooth, or if you are a general dentist managing a patient with an immature permanent tooth and pulpal compromise, specialist endodontic assessment at Smile Solutions provides the diagnostic precision and clinical expertise these cases demand.

For related reading, see our guides on Traumatic Dental Injuries and Emergency Endodontics: What to Do When a Tooth Is Knocked Out or Cracked, Root Canal Pain and Anaesthesia: Does Root Canal Treatment Hurt in 2025?, and Root Canal Success Rates and Long-Term Outcomes: What the Clinical Evidence Shows.

Smile Solutions has been providing specialist endodontic care from Melbourne's CBD since 1993. Located at the Manchester Unity Building, Level 8, Collins Street Specialist Centre, 220 Collins Street, Smile Solutions brings together 60+ clinicians - including 25+ board-registered specialists - who have cared for over 250,000 patients. No referral is required to book a specialist appointment. Call 13 13 96 or visit smilesolutions.com.au to arrange your specialist endodontic consultation.

References

• Alqaderi, H., et al. "Treatment Outcomes of Pulpotomy in Primary Teeth with Irreversible Pulpitis: A Systematic Review and Meta-Analysis." Children (MDPI), Vol. 11, No. 5, 2024. https://www.mdpi.com/2227-9067/11/5/574

• Pires, C.W., et al. "Clinical and Radiographic Success of Pulpotomy and Pulpectomy in Primary and Permanent Teeth: A Systematic Review and Meta-Analysis." PMC / Journal of Clinical Dentistry, 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11470449/

• Shabahang, S. "Treatment Options: Apexogenesis and Apexification." Journal of Endodontics, Vol. 39, No. 3 Suppl, 2013. https://www.jendodon.com/article/S0099-2399(12)01123-5/fulltext

• Murray, P.E. "Review of Guidance for the Selection of Regenerative Endodontics, Apexogenesis, Apexification, Pulpotomy, and Other Endodontic Treatments for Immature Permanent Teeth." International Endodontic Journal, 2023. https://onlinelibrary.wiley.com/doi/10.1111/iej.13809

• Dhar, V., et al. "Success of Medicaments and Techniques for Pulpotomy of Primary Teeth: An Overview of Systematic Reviews." International Journal of Paediatric Dentistry, 2022. https://pubmed.ncbi.nlm.nih.gov/35271753/

• Petti, S., Glendor, U., & Andersson, L. "World Traumatic Dental Injury Prevalence and Incidence, a Meta-Analysis - One Billion Living People Have Had Traumatic Dental Injuries." Dental Traumatology, Vol. 34, No. 2, 2018. (As cited in StatPearls, NCBI Bookshelf.) https://www.ncbi.nlm.nih.gov/books/NBK580475/

• Mohammadi, Z., & Dummer, P.M.H. "An Update on Local Anesthesia for Pediatric Dental Patients." Journal of the California Dental Association, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/

• Flores, M.T., et al. (BMC Oral Health). "Paediatric Dental Trauma: Insights from Epidemiological Studies and Management Recommendations." BMC Oral Health, 2025. https://bmcoralhealth.biomedcentral.com/articles/10.1186/s12903-024-05222-5

• Assiri, H., et al. "Open Apex and its Management: Review Article." PMC / Journal of International Oral Health, 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11000961/

• Dental Board of Australia. "Specialist Registration - Endodontics." Dental Board of Australia, 2024. https://www.dentalboard.gov.au