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

Assessment of masticatory performance in pediatric patients receiving preformed crowns by Hall technique: a controlled clinical trial

PURPOSE

The purpose of the study was to assess and compare the masticatory performance in children receiving preformed metal crown by Hall technique and conventional technique.

METHODS

Children having teeth indicated for restorative/endodontic therapy and belonging to the age group of six to ten years were invited to participate in the study. Eighteen children received preformed metal crowns (PMCs) by Hall technique. Meanwhile, nineteen children received preformed metal crowns by the conventional technique. Their masticatory performance (MP) was assessed at T0 (pre-intervention), T1 (day 1 post-intervention), T2 (1 week), T3 (2 weeks), T4 (1 month) and T5 (3 months) using Hue-check Gum® (University of Bern, Switzerland). The chewing gum samples were scanned within 24 h of their collection and processed in the ViewGum Software©. The software calculated the hue value (VOH) which indicated the masticatory performance of the individual. A questionnaire was given to the parents at T4 and T5 to assess any discomfort or pain associated with PMCs placed in both groups.

RESULTS

The evaluation of masticatory performance using the two-color chewing method revealed reduction in MP on day 1 post-intervention (p < 0.001) for both groups. However, the MP values recorded at T5 were comparable to the baseline values at T0 (p = 0.009). No significant discomfort or pain was reported in both groups.

CONCLUSION

The findings of the current clinical study indicate that placement of PMCs by both conventional and Hall technique in children deteriorates their MP which equilibrates within 1 month.

CLINICAL TRIAL REGISTRY OF INDIA NUMBER

CTRI/2021/02/031532 [Registered on: 25/02/2021]-Trial Registered Prospectively.

The clinical success of ART restorations and Hall technique in primary molars: a randomized 18-month follow-up study

Objectives

The aim of the study was to evaluate the clinical and radiographic success of the Hall technique (HT) and atraumatic restorative treatment (ART) restorations using high-viscosity glass-ionomer cement for the management of occlusal carious lesions in primary molars.

Materials and Methods

This randomized clinical study observed 40 children (aged 5-6 years). For each child, one tooth was treated with HT and one with ART. The primary outcome measures for HT restorations were successful, minor, and major failure rates. Clinical evaluations of ART restorations were performed according to the modified United States Public Health Service criteria during 18-month follow-up. McNemar test was used for statistical analysis.

Results

Thirty of 40 (75%) participants returned for 18 months of follow-up. In the clinical evaluations of teeth that were treated with HT, the patients did not have complaints of pain or other symptoms, all crowns remained in the oral cavity, the gums were healthy, and the teeth were functional in all evaluations. At the end of the 18-month follow-up, the surface texture and marginal integrity criteria of ART restorations were recorded as 26.7% and 33.3%, respectively. In the radiographic evaluation of 30 patients treated with ART and HT, all restorations were considered successful.

Conclusions

The 18-month clinical and radiographic results after treatments applied to single-surface cavities in anxious children showed that both treatment methods were successful.

Confidence-level of foundation dentists in the North West of England in the placement of preformed metal crowns using the Hall technique

INTRODUCTION

The Hall technique is a biological caries management approach commonly used within the field of paediatric dentistry. The technique involves the placement of a preformed metal crown (PMC) without local anaesthetic, caries removal or tooth preparation. Despite being widely taught across dental schools in the United Kingdom, evidence from the literature suggests that PMCs are seldom used in general dental practice, even by newly qualified dentists. This study aimed to evaluate the experience and self-reported confidence of Foundation Dentists (FDs) in the North West of England in the placement of preformed metal crowns using the Hall technique.

MATERIALS AND METHODS

An anonymous questionnaire was distributed to 117 Foundation Dentists in the North West of England.

RESULTS

Forty-six questionnaires were returned, giving a response rate of 39%. The results revealed that 80.4% of FDs felt "somewhat," "quite" or "extremely" confident with the Hall technique at the point of graduation. This increased to 85.3% upon completion of Dental Foundation Training.

CONCLUSION

Foundation Dentists' self-reported confidence in the Hall technique was reasonably high both at the point of qualification and upon completing Dental Foundation Training. Nevertheless, many of the Foundation Dentists felt that they would benefit from further postgraduate training on the technique.

When (and when not) to use the Dahl Concept

The Dahl Concept describes the re-establishment of occlusal contacts after the provision of a planned localised appliance or restoration in supraocclusion. Initially developed to create space for prosthetic rehabilitation of anterior teeth suffering from localised wear, the principle has later been successfully applied to a variety of situations, including the Hall technique and resin-bonded bridges cemented in supraocclusion. Despite high levels of success seen in the relevant literature and widespread adoption in specialist care, the wider profession appears to be far more cautious in its use. This article aims to provide a brief summary of the Dahl Concept and discuss the local and general factors that influence its successful implementation in the hope of promoting its increased adoption by the broader dental profession.

Minimal Intervention Dentistry (MID) mainstream or unconventional option? Study exploring the impact of COVID-19 on paediatric dentists' views and practices of MID for managing carious primary teeth in children across the United Kingdom and European Union

Purpose

To explore the techniques used to manage carious primary teeth during the COVID-19 pandemic by paediatric dentists and dentists with a special interest in paediatric dentistry (DwSI) who are members of the British Society of Paediatric Dentistry (BSPD) and the European Academy of Paediatric Dentistry (EAPD), and their views on the use of minimal intervention dentistry (MID) in children prior to, during and post the COVID era.

Methods

A total of 212 paediatric dentists and DwSI completed an online questionnaire. Six MID techniques were explored: fissure sealants, resin infiltration, Hall Technique (HT), 38% silver diamine fluoride (SDF), atraumatic restorative treatment (ART), stepwise removal and selective caries removal.

Results

The majority were specialists (26%) followed by clinical academics (23.1%) working mainly in university teaching hospitals (46.2%). Routine dental treatment for children with carious primary teeth was provided by the majority (92.5%) during the pandemic. HT (96%) and 38% SDF (65.7%) were the most commonly used techniques among the BSPD members whereas conventional restoration of non-selective caries removal and pulp therapy remained the most widely used technique among the EAPD members (66.2%). Most of the MID techniques were used as a treatment option (48.1%) rather than a choice (43.4%), with most of these choices having been affected by the patient’s behaviour (82.5%). More than one thirds (39.2%) of the participants were reluctant to adopt MID after the pandemic. Several barriers such as lack of teaching and confidence as well as perceived lack of evidence were identified.

Conclusion

A range of MID techniques is practiced broadly by a sample of paediatric dentists and DwSI across the United Kingdom (U.K) and European Union (E.U). The majority of clinicians are willing to continue using these techniques going forward after COVID restrictions are lifted. The pandemic served as an opportunity for many dentists to become familiar with various MID practices, such as SDF, which has been already established some time ago.

Cost-effectiveness analysis of silver diamine fluoride to divert dental general anaesthesia compared to standard care

BACKGROUND

The aim is to perform a model-based cost-effectiveness analysis of a silver diamine fluoride (SDF) protocol intervention to divert dental general anaesthesia (DGA) among Victorian children aged 2- 10 years.

METHODS

Data inputs was based on an Australian single-cohort 2017/18 study. Intervention costs for standard care were derived from two subgroups of children: 1) children who received standard care without DGA, and 2) children who received standard care with DGA. Two scenarios were modelled due to limited post-follow-up data: 1) children receiving SDF had standard care without DGA (base-case scenario), and 2) children receiving SDF did not receive standard care without DGA (alternative scenario). A simple decision-tree model with probabilistic sensitivity analysis (PSA) estimated the incremental costs per diverted DGA.

RESULTS

The probability of children requiring specialist referral and offered SDF, but the primary carer opted for DGA is 0.124 (SD 0.034), and the probability of children requiring DGA in standard care is 0.346 (SD 0.036). For both the base-case and alternative scenario, the incremental cost-effectiveness ratio outcome is dominant and their cost-effectiveness being either 74.8% or 100%, respectively.

CONCLUSIONS

The SDF protocol intervention is cost-effective dental caries management option for young children where referral for DGA is considered. © 2022 Australian Dental Association.

Clinical and Microbiological Evaluation of a Chlorhexidine-Modified Glass Ionomer Cement (GIC-CHX) Restoration Placed Using the Atraumatic Restorative Treatment (ART) Technique

The aims of this study were to investigate the clinical effectiveness and patient acceptability of a modified glass ionomer cement placed using the atraumatic restorative treatment (ART) technique to treat root caries, and to carry out microbiological analysis of the restored sites. Two clinically visible root surface carious lesions per participant were restored using ART. One was restored with commercial glass ionomer cement (GIC) (ChemFil® Superior, DENTSPLY, Konstonz, Germany) which acted as the control. The other carious root lesion was restored with the same GIC modified with 5% chlorhexidine digluconate (GIC-CHX; test). Patient acceptability and restoration survival rate were evaluated at baseline and after 6 months. Plaque and saliva samples around the test and control restorations were collected, and microbiological analysis for selected bacterial and fungal viability were completed at baseline, and after 1, 3, and 6 months. In total, 52 restorations were placed using GIC and GIC-CHX in 26 participants; 1 patient was lost to follow-up. After reviewing the restorations during their baseline appointments, participants indicated that they were satisfied with the appearance of the restorations (n = 25, 96%) and did not feel anxious during the procedure (n = 24, 92%). Forty-eight percent (n = 12) of the GIC-CHX restorations were continuous with the existing anatomic form as opposed to six for the GIC restorations (24%), a difference which was statistically significant (p = 0.036). There was no statistically significant reduction in the mean count of the tested microorganisms in plaque samples for either type of restorations after 1, 3, or 6 months. Restoration of carious root surfaces with GIC-CHX resulted in higher survival rates than the control GIC. ART using GIC-CHX may therefore be a viable approach for use in outreach dental services to restore root surface carious lesions where dental services are not readily available, and for older people and special needs groups.

Interventions for treating cavitated or dentine carious lesions

BACKGROUND

Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

OBJECTIVES

To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps.

SEARCH METHODS

An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions.

MAIN RESULTS

We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

AUTHORS' CONCLUSIONS

Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

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.

Influences on dentists' adoption of nonsurgical caries management techniques: A qualitative study

BACKGROUND

Nonsurgical caries management techniques (NSCMT) offer a simple, conservative approach to treating caries. Despite evidence supporting and potential advantages of NSCMT, dentists can be reluctant to adopt these techniques. To better understand this phenomenon, the authors interviewed dentists who primarily treat children regarding their thoughts, attitudes, and adoption of 3 NSCMT.

METHODS

The 3 NSCMT were fluoride varnish, silver diamine fluoride, and Hall stainless steel crowns. The authors interviewed dentists in North Carolina whose practices were restricted mostly to children. A nonprobabilistic maximum-variation design was used in the sampling. Using a semistructured interview guide, the authors recorded the interviews digitally and analyzed them thematically. The authors stratified the analysis according to years of practice, geographic location, and type of practice. Reporting was based on emerging and recurring themes and insightful quotes.

RESULTS

Factors most likely to promote the adoption of NSCMT were related to clinical practice, family preference, patient safety, and provider philosophy. Barriers to adoption included previous practitioner negative experiences using the techniques, high-risk caries population, and perceived likelihood of negative outcomes. Characteristics of the practice environment, patient population, communication with families, and financial considerations were influential in the clinician's determination as to whether to use these techniques.

CONCLUSIONS

These findings provide valuable insight into practitioners' influences, motivations, and clinical decision making in the adoption and use of management and treatment approaches for carious lesions in the pediatric population.

PRACTICE IMPLICATIONS

The primary factors and barriers identified in this study are possible targets for education and quality improvement programs aimed at increasing NSCMT use.

Pediatric Stainless-Steel Crown Cementation Finite Element Study

Objective  To study the effect of using different cement types under pediatric stainless-steel crown (SSC) around mandibular second primary molar using three-dimensional (3D) finite element analysis.

Materials and Methods  A 3D finite element model was built for pediatric mandibular molar by laser scanning of natural extracted tooth. Four types of cement (zinc phosphate, glass ionomer, resin-modified glass ionomer, and resin) of 200 μm layers thickness were tested under a stainless-steel crown of 130-μm thickness. Twelve case studies were reported within this research, as the applied load of 330 N was tested with three angulations: vertical, oblique at 45°, and laterally.

Results  Linear static stress analysis was performed. The resultant stresses and deformations' distribution patterns did not change with cement type, while the values were altered. All deformations and stresses were found within the normal range.

Conclusions  Analysis results indicated that using stiffer cement material increases tooth structure stresses and reduces crown body stresses and deformations, while bone was nearly insensitive to cement type.

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.

The use of Hall technique preformed metal crowns by specialist paediatric dentists in the UK

Examines treatment planning involving Hall technique preformed metal crowns by specialists in paediatric dentistry.

Explores clinical situations in which specialists in paediatric dentistry feel it is appropriate or not to fit Hall technique preformed metal crowns.

Investigates which types of carious lesions are being treated with Hall technique preformed metal crowns by specialists in paediatric dentistry.

Background Hall technique preformed metal crowns (HTPMCs) have been increasing in use recently, but little is currently known about their use by specialists.

Aim To investigate the views and usage of HTPMCs by UK specialist paediatric dentists.

Design This was a prospective questionnaire-based study, distributed online to all specialists on the British Society of Paediatric Dentistry email list between July and September 2014.

Results Ninety-four questionnaires were completed. The majority of respondents, 65% (61) worked in teaching hospitals, followed by community dental services, 37% (35). Ninety-six percent (89) reported that they used HTPMCs in their practice. Fifty-eight percent (54) used HTPMCs as a treatment option for restoring symptomless carious primary molars, and 15% (14) only when unable to provide conventional restoration. Twenty-three percent (21) used HTPMCs as the treatment of choice. Only 4% (4) of respondents never used them. Sixty percent (53) had been using HTPMCs for over five years. Seventy-six percent (68) would consider placing HTPMCs under inhalation sedation, and 26% (23) under general anaesthesia. Over 90% (85) believed that HTPMCs are suitable for undergraduate teaching, general practice, postgraduate training and specialist practice.

Conclusion HTPMCs are widely used among specialist paediatric dentists in the UK.

Fluorides and Other Preventive Strategies for Tooth Decay

We focus on scalable public health interventions that prevent and delay the development of caries and enhance resistance to dental caries lesions. These interventions should occur throughout the life cycle, and need to be age appropriate. Mitigating disease transmission and enhancing resistance are achieved through use of various fluorides, sugar substitutes, mechanical barriers such as pit-and-fissure sealants, and antimicrobials. A key aspect is counseling and other behavioral interventions that are designed to promote use of disease transmission-inhibiting and tooth resistance-enhancing agents. Advocacy for public water fluoridation and sugar taxes is an appropriate dental public health activity.