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Objective: To observe whether paediatric dentists and orthodontists balance and compensate the extraction of first permanent molars (FPMs) in children aged 7–11 years. Design: Service evaluation. Setting: UK dental teaching hospital. Methods: Retrospective analysis of FPM extraction patterns in patients aged 7–11 years that attended for extraction of FPMs from 1 January 2019 to 31 January 2020 (13-month period). Results: A total of 194 patients were included and they collectively had 435 FPMs extracted. No balancing extractions to prevent dental centreline shifts and no lower FPM compensatory extractions were performed. Compensatory extraction of good prognosis upper FPMs were performed in 64% (94/146) of cases to avoid overeruption. Orthodontic input was sought for poor prognosis lower FPMs in 76% of cases compared to 51% for poor prognosis upper FPMs. Conclusion: Compensatory extraction of good prognosis upper FPMs to avoid overeruption appears to be a common practice at Guy’s and St Thomas’ Hospitals. There was also higher demand for orthodontic advice for cases presenting with poor prognosis lower FPMs compared to poor prognosis upper FPMs, which suggests that paediatric dentists may prefer for the final decision on upper FPM compensatory extractions to be made by an orthodontist, even with national guidelines available. More high-quality research on the topic is required to determine the necessity of this practice for achieving optimal long-term oral health in children.