Modern approaches to caries management of the primary dentition

Hall technique for primary teeth: A systematic review and meta-analysis

Background

There has been a debate about the use of Hall Technique (HT), whether it can be considered as a standard technique for the management of carious primary molars.

Aim

To summarise the evidence on HT for managing dentine caries in primary teeth.

Design

MEDLINE, Embase, CENTRAL and Epistemonikos databases were searched for clinical studies conducted from 2007 to 2021 evaluating HT in primary teeth. Two reviewers independently screened, data extracted and quality assessed the studies.

Results

Eleven publications from eight unique studies were included. Four were of low risk of bias overall and five studies were included in a meta-analysis. Overall, HT was 49 % (RR 1.49 [95 % CI: 1.15–1.93], I² =89.5 %, p < 0.001) more likely to succeed. When compared to direct restorations, HT was 80 % more likely to succeed; while similar success was found when compared to conventional preformed metal crowns. HT was also over 6 times (RR 0.16 [95 %CI: 0.10–0.27], I² =0 %, p < 0.001) less likely to fail. Most of the studies included proximal or multi-surface lesions.

Conclusions

HT is successful option for the management of caries in primary teeth, particularly for proximal or multi-surface dentine lesions. It is well-tolerated by children and acceptable to parent, with mild adverse effects reported.

Stainless-steel crowns in children: Norwegian and Finnish dentists' knowledge, practice and challenges

BACKGROUND

Stainless-steel crowns (SSCs) are recommended for restorative treatment of young teeth severely affected by caries, fractures or dental developmental disorders (DDDs). However, despite recommendations and clinical evidence, SSCs are not widely used by general dentists, who favour extraction and more conventional restorations. The present study aimed to investigate the views of and use of SSCs among Norwegian and Finnish dentists.

METHODS

The present study was a cross-sectional survey among Norwegian and Finnish dentists. An electronic questionnaire was sent to Norwegian and Finnish dentists asking whether they used SSCs and on which indications. In addition, the questionnaire assessed reasons for non-use and dentists' perceptions regarding advantages and challenges in the use of SSCs, as well as the need for additional training. Distributions of background characteristics, use of and views on SSCs were calculated, and statistical significance of the associations between respondents' background and their answers were evaluated.

RESULTS

Of the 574 Norwegian and 765 Finnish respondents, only 12.0% and 12.9% reported to use SSCs, respectively. The most frequently reported barrier reported by those who did not use SSCs was lack of practical training. The most frequent challenge reported by those using SSCs was difficulties in crown adjustment followed by aesthetic issues, and the most frequently reported advantage was that SSCs maintain the function and occlusion. The majority of respondents reported a need for more information and practical training in the use of SSCs, with hands-on course as their most frequently preferred education type.

CONCLUSION

Although the value of SSCs for restoring young molars is recognized by Norwegian and Finnish dentists, SSCs are rarely used by general dentists. The majority of the respondents reported lack of training and materials and was interested in receiving more information and education.

A 24-month retrospective study of preformed metal crowns: the Hall technique versus the conventional preparation method

PURPOSE

Conventional and Hall Technique (HT) Preformed Metal Crowns (PMCs) are used for treatment of carious primary molars. The aim was to evaluate the clinical and radiographic success of conventional and HT PMCs in a postgraduate dental setting.

METHODS

A retrospective study using patients' electronic case-notes and radiographic images of carious primary molars treated with either conventional or HT PMCs was conducted to assess clinical and radiographic success/failure. A Kaplan-Meier curve was used to assess PMC survival.

RESULTS

187 PMCs (110 HT and 77 conventional) in 65 children (34 females and 31 males) at 6, 12, 18 and 24 months were assessed. At 24 months, the success rates of conventional and HT PMCs were 97.6% and 93.5%, respectively. Two HT (perforated/abscessed) and four conventional (abscessed) PMCs failures occurred. There was no significant difference in success/failure (p = 0.362) at 12 months, but the HT was more successful at 24 months (p = 0.002) with similar survival times for both methods.

CONCLUSION

HT and conventionally placed PMCs, when placed in a postgraduate paediatric dentistry setting, were clinically and radiographically very successful at 6, 12, 18 and 24 months post operatively with a slightly higher success of the HT at 24 months.

Temporomandibular dysfunction assessment in children treated with the Hall Technique: A pilot study

BACKGROUND

The Hall technique (HT) involves the placement of stainless steel crowns for treating asymptomatic carious primary teeth without tooth preparation or caries excavation.

AIM

To investigate whether temporomandibular dysfunction (TM-D) manifests in children after HT.

DESIGN

Healthy children (age: 5-9 years) with dentin caries were treated with HT in a university clinic, and TM-D signs and symptoms were monitored in this cohort clinical trial. The primary outcome was TM-D signs recorded using the clinical dysfunction index (Di) at pre-treatment: 0-, 1-, 3-, 6-, and 12-month follow-up visits. The secondary outcome was TM-D symptoms recorded using a questionnaire. The Di and symptoms were compared over time using McNemar's tests.

RESULTS

Thirty-nine children were followed for 12 months after HT treatment. Four children were detected as having dysfunction signs throughout the study: muscle pain on palpation and clicking. The symptoms 'hearing a sound within the jaw joint' or 'bite felt uncomfortable or unusual' were reported by another four children. The Di and TM-D symptoms were not significantly different between pre-treatment and follow-up visits (P > .05).

CONCLUSIONS

The HT does not seem to be connected to TM-D. Alternative TM-D assessment tools for studying non-persistent symptoms more comprehensively might be useful for future studies.

Use of the Hall technique by specialist paediatric dentists: a global perspective

Background The Hall technique (HT) is popular with UK paediatric dentists (PDs). Global PDs perception/use of HT is unknown.Aim To investigate global PDs opinions/use of HT.Materials and methods A cross-sectional questionnaire of 26 questions was sent to specialist PDs across the globe.Results Responses of 709 PDs from six continents were obtained. The majority (n = 654, 92.32%) had heard about HT but only 50.6% (n = 358) used it, with wide country variations. Respectively, 37.5%, 31.5% and 31% were neutral, against or supportive of HT when they initially heard about it. Only 17% of HT users said it was always the treatment of choice for non-pulpal asymptomatic carious primary molars (NPACPMs), 62% would take a pre-operative radiograph, 65% would consider using high speed drills before HT, 63% would never consider HT under general anaesthesia, 56% would use HT under N₂O sedation. Finally, in a clinical scenario of a NPACPM in a cooperative 6-year-old, 75% of PDs would choose conventional restorative methods over the HT.Conclusion The HT is recognised, but not used, by an outright majority of PDs across the globe. Identifiable barriers such as lack of training, perception as substandard dentistry and perceived lack of evidence reduced its use.

Influence of antimicrobial photodynamic therapy in carious lesion. Randomized split-mouth clinical trial in primary molars

BACKGROUND

The literature presents many studies regarding photodynamic antimicrobial therapy (aPDT). However, the great variety of protocols to be used can directly influence its effectiveness in reducing microorganisms. The aim of this randomized split-mouth clinical study was to evaluate the effect of aPDT in the reduction of Streptococcus mutans and their effect on restorations performed.

METHODS

Twenty children between 6 and 8 years old with active caries and dentin cavitation, located on the occlusal surface of homologous primary molars were included. The selective removal of carious tissue was performed in both molars, than one was subsequently restored and the other received aPDT treatment on the affected dentin with low intensity laser (InGaAlP) associated to 0.005% methylene blue photosensitizer before restoration. Dentin collections were performed only in the tooth submitted to aPDT in three moments: before and after selective caries removal and after application of aPDT. The restorations were analyzed after polishing and after 6 months using United States Public Health Service (USPHS) method. Data were analyzed using ANOVA with repeated measures and Bonferroni post-hoc test with a significance level of 5%.

RESULTS

There was a significant reduction on the amount of microorganisms after selective caries removal (p = 0.04) and also after the application of aPDT (p = 0.01). The reduction of S. mutans CFU was of 76.4% after caries removal, but associated with aPDT was 92.6%. After 6 months of clinical evaluation, no difference between groups was found for retention, marginal adaptation, color, marginal discoloration, and secondary caries.

CONCLUSIONS

aPDT can be used as an additional treatment against cariogenic microorganisms after selective caries removal without compromising composite resin restorations.

[Application of minimally invasive cosmetic dentistry in the clinics of pediatric dentistry]

With the minimally invasive treatment attracting considerable attention in the field of dentistry, a series of oral minimally invasive treatment technologies, including minimally invasive cosmetic dentistry (MICD) technology, is emerging. Children, as a special group of patients, are in the critical stage of the initial formation of psychological structure. Therefore, children's dental treatment should not be limited to restoring function and relieving pain. The development, aesthetics, and physical and mental health should also be given attention. Therefore, in recent years, MICD technology has been widely used in diagnosis and treatment of pediatric dentistry. This review provides a detailed introduction regarding a series of techniques in pediatric dentistry.

Clinical and Radiographic Success of Selective Caries Removal to Firm Dentin in Primary Teeth: 18-Month Follow-Up

The selective caries removal is increasingly spreading in daily clinical practice because this minimally invasive technique treats deep carious lesion and decreases the risk of pulp exposure. This case report was aimed at describing the selective removal to firm dentin on the primary mandibular left first molar of a girl aged 7 years and 6 months. The Mineral Trioxide Aggregate (MTA Angelus™) was used as liner, and the tooth was definitively restored with resin-modified glass ionomer cement (Vitremer™). The clinical and radiographic following-up was performed at 6, 12, and 18 months after treatment. The treatment showed satisfactory results after 18-month following-up, suggesting that this minimally invasive approach for carious lesion removal can replace the total removal, when properly indicated. Notwithstanding, further randomized clinical trials with longer following-up periods are still necessary.

Alternative Caries Management Options for Primary Molars: 2.5-Year Outcomes of a Randomised Clinical Trial

Less invasive caries management techniques for treating cavitated carious primary teeth, which involve the concept of caries control by managing the activity of the biofilm, are becoming common. This study aimed to compare the clinical efficacy (minor/major failures) and survival rates (successful cases without any failures) of 3 carious lesion treatment approaches, the Hall Technique (HT), non-restorative caries treatment (NRCT), and conventional restorations (CR), for the management of occlusoproximal caries lesions (ICDAS 3-5) in primary molars. Results at 2.5 years are presented. A total of 169 children (3- to 8-year-olds) were enrolled in this secondary care-based, 3-arm parallel-group, randomised controlled trial. Participants were allocated to: HT (n = 52; sealing caries with stainless-steel crowns without caries removal), NRCT (n = 52; opening up the cavity and applying fluoride varnish), CR (n = 65; control arm, complete caries removal and compomer restoration). Statistical analyses were: non-parametric Kruskal-Wallis analysis of variance, Mann-Whitney U test and Kaplan-Meier survival analyses. One hundred and forty-two participants (84%; HT = 40/52; NRCT = 44/52; CR = 58/65) had follow-up data of 1-33 months (mean = 26). Overall, 25 (HT = 2, NRCT = 9, CR = 14) of 142 participants (17.6%) presented with at least 1 minor failure (reversible pulpitis, caries progression, or secondary caries; p = 0.013, CI = 0.012-0.018; Mann-Whitney U test). Ten (HT = 1, NRCT = 4, CR = 5) of 142 participants (7.04%) experienced at least 1 major failure (irreversible pulpitis, abscess, unrestorable tooth; p = 0.043, CI = 0.034-0.045). Independent comparisons between 2 samples found that NRCT-CR had no statistically significant difference in failures (p > 0.05), but for CR-HT (p = 0.037, CI = 0.030-0.040) and for NRCT-HT (p = 0.011, CI = 0.010-0.016; Kruskal-Wallis test) significant differences were observed. Cumulative survival rates were HT = 92.5%, NRCT = 70.5%, and CR = 67.2% (p = 0.012). NRCT and CR outcomes were comparable. HT performed better than NRCT and CR for all outcomes. This study was funded by the Paediatric Dentistry Department, Greifswald University, Germany (Trial registration No. NCT01797458).

Interim therapeutic restoration approach versus treatment under general anaesthesia approach

BACKGROUND

Although dental treatment under general anaesthesia (GA) remains the long-established approach for treating anxious children, treatment under GA presents with increased risks, costs and parental acceptability issues. Interim therapeutic restoration (ITR) has been proposed as an alternative approach.

AIM

To compare the incidence and types of failures between children managed with the ITR approach and those managed under GA within 12 months of treatment completion.

DESIGN

A retrospective cohort study of children who received dental treatment utilizing the ITR approach was compared to children treated under GA. Age, gender and dental disease matching was done. Statistical analyses were carried out with Independent t-test and chi-square analyses.

RESULTS

A total of 132 children (GA = 66, ITR = 66) were included, and the groups did not differ in terms of initial age, sex, dmft and initial behaviour score. ITR group had a significantly higher rate (P < 0.001; 95% CI: [0.21 to 0.97]) of restorative failure and visits required when compared to the GA group. There were no difference for incidence of pain (P = 0.55; 95% CI: [-0.074 to 0.10]) and behaviour scores (P = 0.46) between the two groups at the 12-month visit.

CONCLUSIONS

ITR approach may be a viable alternative to the GA approach when treating paediatric dental patients.

Managing Carious Lesions: Consensus Recommendations on Terminology

Variation in the terminology used to describe clinical management of carious lesions has contributed to a lack of clarity in the scientific literature and beyond. In this article, the International Caries Consensus Collaboration presents 1) issues around terminology, a scoping review of current words used in the literature for caries removal techniques, and 2) agreed terms and definitions, explaining how these were decided.Dental cariesis the name of the disease, and thecarious lesionis the consequence and manifestation of the disease-the signs or symptoms of the disease. The termdental caries managementshould be limited to situations involving control of the disease through preventive and noninvasive means at a patient level, whereascarious lesion managementcontrols the disease symptoms at the tooth level. While it is not possible to directly relate the visual appearance of carious lesions' clinical manifestations to the histopathology, we have based the terminology around the clinical consequences of disease (soft, leathery, firm, and hard dentine). Approaches to carious tissue removal are defined: 1)selective removal of carious tissue-includingselective removal to soft dentineandselective removal to firm dentine; 2)stepwise removal-including stage 1,selective removal to soft dentine, and stage 2,selective removal to firm dentine6 to 12 mo later; and 3)nonselective removal to hard dentine-formerly known ascomplete caries removal(technique no longer recommended). Adoption of these terms, around managing dental caries and its sequelae, will facilitate improved understanding and communication among researchers and within dental educators and the wider clinical dentistry community.

The Hall Technique; retrospective case-note follow-up of 5-year RCT

BACKGROUND AND AIM

Few paediatric dental restorative trials present outcomes for more than two years, leaving clinicians uncertain of long-term implications for their patients. This study aimed to establish the Hall Technique's success over the lifetime of primary teeth compared to conventional restorations (CR), by following up participants in the Tayside (Scotland), UK trial.

DESIGN

Following the Phase 1 prospective, split-mouth randomised control trial with 132 children (264 teeth) in 17 general practices in Scotland, 142/264 (54%) teeth had reached an endpoint of exfoliation or extraction. Through practices, Phase 2 follow-up data were collected retrospectively from case-notes, using original trial outcomes. Phase 1/ 2 outcome data were combined.

RESULTS

Data were obtained up until exfoliation/extraction for 184 teeth (73%) in matched pairs. Major failures: 16 CR; 4 HT (P = 0.0015); ARR = 0.13 (95%CI: 0.04;0.22), numbers needed to treat (NNT) 8 (95%CI: 4;25) favouring HT. Minor failures: 37 CR; 5 HT (P <0.0001); ARR = 0.35 (95%CI: 0.23;0.45) and NNT = 3 (95%CI: 2;4). Repeat failures occurred mostly in the conventional restoration arm for both major and minor failures.

CONCLUSIONS

The HT continued to outperform GDP's standard restorations in primary molar teeth with significant caries involvement over the lifetime of the teeth.

Materials for Paediatric Dentistry. Part 1: Background to the Treatment of Carious Primary Teeth

Dental caries is a disease that affects many people, including children, and presents numerous challenges to healthcare providers. As clinicians it is important that we consider the advantages and disadvantages of treating carious primary teeth, and make an informed decision about when it is appropriate or not. This paper describes the background to the treatment of carious primary teeth, looking at the differences between primary and permanent teeth, and the relevance of this. It also suggests points to consider when looking at restoration survival studies, as the ability to appraise the literature critically is important for us all in this 'evidence-based' age. CPD/Clinical Relevance: Our early life experiences have the ability to shape our future attitudes and behaviour. Children with carious teeth require careful management so that pain and suffering is minimized, and positive attitudes towards dentistry are fostered.

Materials for Paediatric Dentistry. Part 2: The Evidence

Which materials should be used to restore primary teeth? The second part in this series summarizes the current evidence base relating to this question, and describes the biological approach to caries management. CPD/Clinical Relevance: Our decisions regarding material choices should be based, where possible, on up-to-date evidence. This will help to ensure that the appropriate material is placed in the appropriate clinical scenario.