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For the young patient population, the first permanent molar (FPM) has an extremely high caries rate. Pulp treatment for such severely decayed teeth may be required. As of today, there is no thorough literature review or systematic review that can guide the clinician when making decisions about extraction with second permanent molar (SPM) substitution, or endodontic treatment of a carious FPM. The purpose of this article is to consider the various options for treatment and to look at the cost-benefit picture with respect to their long-term outcomes. A guideline for comparing options such as orthodontic, endodontic, and restorative procedures is presented. It is further suggested that a large study be conducted to gain information in this important area to more precisely guide practitioners in treatment selection.