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

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

When you hear that your child may need a "root canal," it's natural to feel alarmed. The phrase conjures images of lengthy adult procedures, significant discomfort, and irreversible intervention. But at Smile Solutions, endodontic treatment for children and adolescents is understood as a fundamentally different discipline — one governed by developmental biology, the natural lifecycle of primary teeth, and the imperative to protect your child's permanent dentition as it matures.

The procedures used in paediatric and adolescent endodontics — pulpotomy, pulpectomy, apexogenesis, and apexification — are not 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 your child'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 way it is for permanent teeth. Instead, the clinical objective is to maintain the tooth in a healthy, infection-free state until natural exfoliation, 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. Without a vital pulp, dentin deposition stops. Losing pulp vitality in an immature permanent tooth halts root development, leaving the tooth with thin, fragile dentinal walls and an open apex that makes conventional root canal treatment both 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 more common in children than in any other age group. Studies indicate 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 before age 20, making childhood and adolescence particularly vulnerable periods.

The age window from 7 to 10 years is especially risky because the root development of the permanent incisors is still incomplete at that age. A trauma event at precisely the wrong developmental moment can leave your child with an immature permanent tooth requiring specialist endodontic management for years.

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

Pulpotomy for primary teeth: what it is and when it's 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 are teeth with extensive caries, no spontaneous pain, and no evidence of radicular pathology — meaning decay has reached or is very close to the pulp, but infection has not yet spread into the root canals. The high success rates of pulpotomy for primary teeth with irreversible pulpitis reflect the fact that not all cariously exposed pulps are completely infected; inflammation and microbial invasion may be confined to the coronal pulp alone.

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 changed considerably over the past two decades. Formocresol, the historical standard, has been largely replaced because of concerns about its cytotoxicity. Most medicaments and techniques — formocresol aside — achieve success rates above 80% across all domains and time periods, with few meaningful differences in clinical, radiographic, or overall outcomes between them.

Mineral trioxide aggregate (MTA) has been shown to outperform both calcium hydroxide and formocresol in several respects. The most effective long-term restoration for pulpotomised primary teeth is a stainless-steel crown (SSC), which provides superior sealing and full coverage, with higher success rates than IRM, RMGI, or composite restorations.

What does the evidence say about pulpotomy success?

The clinical evidence for pulpotomy in primary teeth is strong. A 2024 systematic review and meta-analysis published in Children (MDPI) found that pulpotomy-treated teeth showed high clinical and radiographic success rates at 6 months (overall success: 97.2%) and 12 months (overall success: 94.4%).

A separate meta-analysis examining Biodentine, a calcium silicate-based material, found a success rate of 98.90% 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 isn't 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 because primary tooth roots are actively resorbing.

Root filling materials for primary teeth must be resorbable, resorbing 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 block the eruption of the permanent tooth.

Current evidence supports 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 pulpotomy and pulpectomy.

Immature permanent teeth: apexogenesis vs. apexification

This is where paediatric endodontics becomes most clinically demanding — and where specialist involvement matters most. 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 remains susceptible to trauma and infection throughout this period.

Teeth without a closed root tip have what is called an "open apex." These teeth cannot be treated with conventional root canals because the tip of the root cannot be sealed in the same way as a fully formed tooth.

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

Apexogenesis is the treatment of a vital pulp in an immature tooth to allow continued root growth and apical closure. It is the preferred approach whenever viable pulp tissue remains, because maintaining pulp vitality allows continued root development along the entire root length.

The dental pulp in young patients is more cellular and better 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 appropriate.

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 your child's 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 an option. Apexification debrides, disinfects, and obturates the root canal of an immature tooth, using calcium hydroxide or MTA to induce an apical calcified barrier and preserve the tooth.

There are two primary approaches:

MTA apexification reduces treatment time and produces more predictable barrier formation than calcium hydroxide. The limitation shared by both approaches is that placing an apical plug does not account for continued root development along the entire root length — the tooth is preserved, but it won't grow further.

Regenerative endodontics: the emerging third option

In cases where the pulp is necrotic and the tooth is very immature with extremely thin dentinal walls, regenerative endodontic procedures (REP) offer an emerging alternative. Regenerative endodontics has the potential to continue root development in immature permanent teeth, which could preserve those teeth for the patient's lifetime.

Case selection is critical, though. Very immature teeth with thin, weak dentinal walls are most prone to fracture and most likely to benefit from regenerative treatment to continue dentinogenesis and strengthen the tooth. That said, conventional endodontic root canal treatment, Cvek partial pulpotomy, apexogenesis, and apexification should always be chosen when they are more likely to benefit the patient — they can be more successful than regenerative endodontics in the right cases.

Choosing between apexogenesis, apexification, and regenerative endodontics is one of the most clinically demanding decisions in endodontics, and a core reason why specialist assessment is recommended for all immature permanent teeth requiring endodontic intervention.

Addressing your concerns: anaesthesia, behaviour, and safety

Is local anaesthesia safe for children?

Yes — local anaesthesia is both safe and essential for paediatric endodontic procedures. Local anaesthetic agents used in paediatric dentistry include lidocaine and prilocaine, typically supplied in cartridges containing 2.2 ml and administered in combination with vasoconstrictor agents such as epinephrine or felypressin to improve haemostasis.

One anatomical point worth knowing: the techniques for achieving local anaesthesia in children are similar to those used in adults, but the reduced bone density of the maxilla and mandible in children allows faster diffusion and absorption of the anaesthetic solution. Anaesthesia is typically achieved faster and with smaller volumes in children than in adults — something our experienced specialists factor into every treatment plan.

What if my child is anxious or uncooperative?

Behaviour management is a core competency in paediatric endodontic care, and at Smile Solutions, our team brings a genuinely gentle approach to every young patient.

For most children over ten, endodontic procedures can be completed comfortably under local anaesthesia alone, with appropriate communication and non-pharmacological behaviour management. Children in this age group are more likely to think abstractly and respond to explanations, which means they can often cooperate with dental treatment 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. The objectives of sedation, as outlined by the Australian Society of Paediatric Dentistry and the Australian Medical Association, include guarding the patient's safety and welfare, minimising physical discomfort and pain, controlling anxiety, minimising psychological trauma, maximising the potential for amnesia, and returning the patient to a safe discharge state.

Communication with parents is central to all of this. When you feel confident and informed, your child is more likely to feel settled too — and at Smile Solutions, we keep you involved at every step.

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 damage the developing permanent tooth beneath it — causing enamel defects, displacement, or disruption of eruption timing.

For immature permanent teeth, long-term outcomes depend heavily on the treatment pathway chosen and how early intervention occurs. The core objective is to preserve pulp vitality to support continuous root development, since pulp viability is the physiological prerequisite for 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 will have a shorter root with thinner walls than one that completed natural development — making appropriate coronal restoration and long-term monitoring particularly important.

Why these cases benefit from specialist endodontic management

Paediatric and adolescent endodontic cases are more complex than adult cases 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 considerable 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, and it can be genuinely difficult to differentiate this from a pathologic radiolucency caused by 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 extruding 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, avoiding damage to the Hertwig epithelial root sheath. Electronic apex locators are generally not accurate in teeth with wide-open apices.

Radiographic interpretation. Cone-beam computed tomography (CBCT) or digital volume tomography overcomes the limitations 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 trained and equipped to manage these cases with clinical precision. The Dental Board of Australia's specialist registration in endodontics requires completion of an accredited postgraduate program covering the full breadth of 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 well-supported by evidence, with systematic reviews reporting overall success rates of 94–97% at 12 months. MTA and calcium silicate-based materials such as 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 your child has a carious primary molar requiring pulpotomy or a traumatised immature incisor requiring apexogenesis, the decisions made in these early years can shape their 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. It also supports having these cases managed by clinicians with specialist training in endodontics, not as an afterthought, but as a starting point.

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. No referral is required, and our team is here to guide you and your child through every step of the process.

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