The FPM is a monophyodont tooth whose development spans several years, from intraosseous formation to functional eruption. It is essential for masticatory function, occlusal stability, and overall oral health. Due to its early eruption, posterior location, complex morphology, immature dental tissues, and children’s limited oral hygiene skills, FPMs are highly prone to caries [1][2]. Yılmaz et al. (2023) reported that FPMs in children aged 7 - 10 years had the highest DMFT (decayed, missing, filled teeth) scores among permanent teeth, highlighting the need for timely preventive and restorative measures [3]. FPMs typically erupt around the age of six. Early diagnosis and management are critical to prevent complications, reduce the need for pulpal or prosthetic treatment, and, in some cases, avoid extractions [4]. Caries in FPMs remain prevalent, affecting 30% - 50% of children aged 6 - 12 and up to 80% of 15-year-olds [5]. Approximately 15% of 7-year-olds present with molar–incisor hypomineralization (MIH), further increasing FPM vulnerability [6]. Severely compromised FPMs may require extraction, which can lead to functional and orthodontic issues if not properly managed [7][8]. Local studies in Morocco show a high prevalence of FPM caries: 65% of children aged 6 - 15 in Rabat had at least one decayed FPM [9] and 72% of children in a recent study at the CCTD in Casablanca had at least one affected FPM, with half presenting with all four involved [10]. These findings underscore the challenges of pediatric dental care, particularly the difficulty of maintaining children’s cooperation and delivering comprehensive treatment within limited clinical time. In this context, the preventive and restorative management of first permanent molars remains a crucial indicator of pediatric dental service quality. Therefore, the present study aims to describe the characteristics of care provided for FPMs in the Pediatric Dentistry Department of Casablanca.

A cross-sectional descriptive study was conducted at the Pediatric Dentistry Department of Casablanca based on a review of archived patient records of children attending the Department during the period of September 2018 to July 2019.

Inclusion criteria: Only fully completed records of children presenting with all four FPMs were included.Exclusion criteria: Incomplete records or files not validated by a supervising professor were excluded.

Data were collected by two supervised dental students after obtaining departmental authorization, using a standardized survey form. The data collection sheet consisted of two main sections: the first concerned patient identification, chief complaint, psychological state, and level of cooperation; the second related to FPM condition, diagnosis, and treatments performed.

The variables included sociodemographic data (age, sex, residence), clinical data (general health, cooperation, decayed/treated FPMs, non-carious pathologies), diagnostic data (type of caries, root maturity), and therapeutic factors (treatment type, number of sessions, treatment abandonment, and referrals).

A pilot study was conducted to test the survey form, and each eligible record was systematically reviewed and included in the study.

Statistical analysis:

Data were analysed using SPSS software. Quantitative variables were expressed by their mean and ± standard deviation, and qualitative variables by frequencies and percentages.

A total of 365 patient records (corresponding to 1460 FPMs) were included in the study. Review of the records showed that 51.2% of patients were boys, with a sex ratio of 1.05, with a mean age of 10.5 ± 3 years. All children included in the study were from urban areas and the majority of them (88.2%) were in good general health.

Regarding child behaviour, 76.4% of the children included in the study were calm, while 7.7% exhibited signs of anxiety and 87.7% of the children were compliant during dental care. (See Table 1)

Table 1. Profile of the patient.

Among the 365 records reviewed, 41 children only 11.2% attended the clinic for reasons directly related to the FPM and regarding multiple FPM involvement, 114 children (29.3%) had at least one affected FPM. Caries and MIH were the most common reported pathologies. The severity of enamel–dentin lesions was distributed as follows: Superficial lesions, Deep lesions, Pulpitis and Pulp necrosis with 43.1%, 11.1%, 1.8%, 3.5% respectively frequencies. (See Table 2)

Table 2. FPM status.

As for therapeutic Interventions, treatment duration and referral to other services, results showed that the treatments performed involved 715 FPMs ranging from simple preventive restoration of 317 molars (44.3%) to extraction 12 molars (1.6%). Among the 365 records reviewed, 83 children who had initiated endodontic treatment, 22% discontinued treatment before completion, while 78% completed their pulpal care. The number of treatment sessions varied from one (89.9%) to seven 0.2 %, depending on the type of intervention. The management of some clinical case the involvement of other specialities, for 8 cases (2.2%), the therapeutic decision regarding was made after a specialized orthodontic consultation, and for 4 cases (1.1%), a consultation with the oral surgery department was sought. (See Table 3)

Table 3. Therapeutic interventions, treatment duration and referral to other services.

The FPM also known as the “six-year molar,” is the first permanent tooth to erupt. It plays a crucial role in occlusion, mastication, and craniofacial development. Despite its importance, the FPM is particularly susceptible to caries due to several factors: early eruption, complex occlusal morphology, posterior position, immature enamel, and children’s limited oral hygiene skills. Furthermore, parental unawareness—often mistaking the FPM for a primary tooth—combined with low socioeconomic and educational levels, can further increase its vulnerability to decay [10].

Results of the present study highlighted the elevated rate of carious FPM in this population of patients attending the Pediatric Dentistry Departement. This finding matches those of two Moroccan studies that investigated the clinical condition of FPM. The first one that was performed by Zouaidi et al. in Rabat (2016) found that 65% of children had a decayed FPM, with caries increasing significantly with age [9], the second one that was conducted by El Omari et al. (2024) in Casablanca reported that 73.1% of children had at least one decayed FPM, mainly on occlusal surfaces [10], with poor parental knowledge and high sugar consumption as major contributing factors. Both studies confirmed the high caries susceptibility of the FPM in Moroccan children and emphasize the importance of early prevention and parental education to preserve this key tooth [10].

Therapeutic decisions regarding the first permanent molar (FPM) are guided by clinical signs (pulp vitality) and radiographic findings (lesion extent, proximity to the pulp, root formation stage), aiming to preserve pulpal vitality, either fully or partially [11].

In our study, preventive treatments were the most commonly provided care (50.1%) because many children consulted at an early stage of caries, before pulp involvement occurred. The first permanent molar (FPM) in these children is particularly susceptible to decay due to its early eruption, posterior location, complex occlusal anatomy, and immature enamel, but when detected early, fissure sealants and preventive restorations are highly effective in protecting the tooth.

Moreover, the high prevalence of preventive care reflects the pediatric prevention and conservative oriented approach in Moroccan dental services, especially in the departments of pedodontics and dental emergencies, where the focus is on preserving pulp vitality and preventing future complications, rather than performing more invasive therapies like restorations or pulp treatment. This strategy is consistent with the aim of reducing premature loss of FPM, which can lead to malocclusion and occlusal disturbances.

These results are consistent with a Lebanese cohort, where preventive procedures represented 48.4% and restorative treatments 41.9%, with low proportions of pulpal treatments and extractions [12]. This comparison suggests that early preventive measures allow preservation of a substantial proportion of FPMs, limiting invasive interventions [13]. In contrast, AlKhalaf et al. in UK (2022) reported a predominance of planned extractions under general anesthesia, likely reflecting differences in disease severity, access to care, and treatment protocols [14][15].

Parental awareness regarding FPM importance remains suboptimal in many settings. A study in rural Ecuador found that children whose parents had better oral health knowledge exhibited lower caries prevalence and severity, highlighting the critical role of parental education in preserving FPM integrity [16].

Regarding treatment duration, in the present study 89.9% of FPM were managed in a single session, and fewer than 3% required three or more sessions. Treatment time is influenced by child cooperation, appointment adherence, and material handling. The quadrant-based approach adopted at the Pediatric Dentistry Department of CCTD of Casablanca treating 2 - 3 teeth per quadrant in one session, streamlines procedures, reduces chair time, and is well tolerated by the child, aligning with recent studies on single-visit pulpectomies and quadrant-based strategies [17][18].

Among children initiating pulpal treatments (83 children), 22% discontinued care due to lack of motivation, long sessions, treatment costs, appointment spacing, and use of manual techniques. These findings align with French studies reporting discomfort, financial constraints, and insufficient understanding as main causes of abandonment [19][20]. While minimally invasive and conservative treatment approaches may contribute to better patient cooperation and continuity of care [21].

Results of this survey showed a low referral rate, with 96.7% of cases managed within the Pediatric Dentistry Department. This can be explained by the multidisciplinary approach adopted by the department, which integrates various specialties such as orthodontics, oral surgery, preventive dentistry, and behavior management, allowing the creation of specialized teams capable of managing most cases in-house and ensuring comprehensive care for children and adolescents. Nevertheless, specialist input remains essential for complex treatments or extractions, highlighting the need for clear referral criteria. Recent literature emphasizes that interdisciplinary collaboration, combining pediatric dentistry, endodontics, orthodontics, and sometimes surgical input, is key for optimal outcomes in children with poor prognosis FPMs [22].

Several measures can be suggested to improve the management of first permanent molars (FPMs):

Include a detailed section on FPMs in the clinical examination form.Prefer mechanized endodontic techniques to reduce treatment time.Ensure regular patient follow-up, including at each semester and during trainee rotations of students.Avoid treating multiple patients simultaneously to optimize appointment management.Schedule shorter and more frequent sessions to minimize treatment abandonment.Achieve thorough mastery of both theoretical and practical aspects of FPM therapies, including instruments and materials.Dedicate a dental chair specifically for preventive care of permanent teeth.Foster an effective patient-practitioner relationship to reinforce preventive measures.

At the institutional level, it is essential that the Ministry of Health and relevant associations (The Moroccan Association for Oral Health Prevention and the Moroccan Pediatric Dentistry Association) develop effective oral health systems, ensure the availability of preventive equipment, and raise awareness among children and parents about the importance of prophylaxis. The first permanent molar should be considered a priority tooth for preventive care to avoid early deterioration and reduce the economic burden on the healthcare system.

This study highlights that preventive and conservative interventions are essential, as most children presented with at least one affected FPM. Effective management relies not only on timely clinical care but also on fostering cooperation, parental awareness, and interdisciplinary collaboration. Prioritizing early preventive strategies can preserve tooth structure, reduce the need for invasive treatments, and ultimately safeguard the oral health of children. As Black insightfully remarked over a century ago: “The day will come when our efforts will be directed more toward prevention than restorative dentistry”.