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20 DENTAL TRIBUNE Middle East & Africa Edition | January-February 2015Clinical < Page 19 Figure 10 (a&b). A patient treated by the author received 7 SSCs using the hall technique. No LA, rubber dam, caries removal or drills were used. They remained free from clinical and radiographic signs and symptoms of pain or sepsis. Compare these with figures 3 (c & d) . Tooth 74 was extracted as it was not restorable. Table 1. Indications and contra-indications of the Hall technique. Figure 11 (a & b). The Hall technique: Figure (11a) shows an OPG radiograph taken at follow up for the same patient seen in Figure 10. There were no clinical or radiographic signs or symptoms of pulpal pathosis. Figure (11b) shows a right bitewing radiograph follow up of SSC using the Hall technique. It shows adequate coverage of the primary molars. The results were an outstanding success rate of 98% for the Hall SSC when compared to the con- trol restorations 85% (in terms of major failures: pain due to pulptitis). The authors conclud- ed that “The Hall Technique was preferred to conventional resto- rations by the majority of chil- dren, carers and GDPs. After two years, Hall PMCs showed more favourable outcomes for pulpal health and restoration longevity than conventional restorations. The Hall Technique appears to offer an effective treatment op- tion for carious primary molar teeth”. In 2011, Innes et al pub- lished similar high success rates in the five year follow up the same study (9). Reaction and response to the Hall Technique There was a mixed international reaction to the development to the Hall technique in paediatric dentistry circles. For example, clinical researchers in Europe reported favourable results af- ter clinically investigating the new method and comparing it with their set conventional tech- niques (13, 14) recommending the Hall technique as an accept- able method in treating primary molar caries. On the other hand, paediatric dentists in the North America initially received the Hall technique with deep skep- ticism. After a joint meeting be- tween the American Academy of Pediatric Dentistry (AAPD) and the Royal College Surgeons of Edinburgh in 2010, where clini- cal methods employed in the USA and UK were compared, the discrepancy between ad- vocates of the Hall technique and the conventional school of thought became apparent. The president of the AAPD stated that “while we may not have agreed with our British and Scottish colleagues on every approach we all agreed that we benefit- ted by seeing how others prac- tice” (15). In line with this, the success of the Hall technique and its study design was ques- tioned in 2012 by Nainar (16). The criticism centered on the control restorations used in the main 2007 study. They were not considered the gold stand- ard restorations that paediatric dentists use in the USA; namely the conventional treatment mo- dality outlined in Figures 1, 2 & 3 above (LA, rubber dam, high speed drill and SSCs). In addi- tion, in vitro laboratory studies showed that SSC cemented us- ing the Hall technique exhibited micro-leakage when using glass ionomer cements (17), however the latter study was not a clini- cal study and the relevance of it to what actually occurs in the mouth was not demonstrated. Finally, and most recently in De- cember 2014, a landmark article was published in the USA sup- porting the use of the Hall tech- nique in dental practice (18). This was a retrospective clinical study, where the authors found that 97% of SSCs placed with the Hall technique and 94 % of SSCs placed with the traditional technique were successful. This study confirmed that the Hall technique was similar in its suc- cessful outcomes to those SSCs placed conventionally. This interesting debate within the paediatric dental circle is still ongoing even as this article is being written, and the debate is often as emotional as it is sci- entific. However, The Hall tech- nique is now becoming more mainstream; it is now taught formally in the undergraduate curricula in 15 out of 16 den- tal schools in the United King- dom (19) and more than half of European paediatric dentistry postgraduates will consider us- ing this technique in managing child patients (20). There had been concerns that Hall SSCs props open the bite after place- ment by 1 mm on average, but there is clinical evidence that the bite resolves itself with dento-alveolar compensation taking place. The bite returns to normal levels within a week (21, 22, 23). A recent abstract submission to the International Association of Dental Research highlighted that mild intrusion of the crowned tooth takes place (22), and this contributed to the self correction of the high bite. This was based on a study that looked at recording the bite, pre/ immediate post op/ & six weeks following SSC placement in 10 patients. The measurements were carried out using photos, clinical measurements, models and laser 3D scanning. The bite had returned to normal levels after 2 weeks (22). Indications for the Hall tech- nique SSCs placed using the Hall tech- nique are not suitable for all child patients with caries. There are selection criteria (21) that should be assessed before con- sidering this technique. These are summarized in Table 1. The dentist should consider the Hall technique as one of the available clinical methods for treating the carious primary molar but not as a replacement for conventional methods. Conclusion Dental caries is an epidemic disease of childhood. While pre- vention is of essence, in a society where dental caries is rampant, its treatment can be challeng- ing especially in young children. The Hall technique for restor- ing the carious primary molar is a newly developed technique that is based on an old concept: deprive caries from sugar sub- strate and it will arrest. The cari- ous lesion needs to be detected early enough before it causes pulpal symptoms, emphasiz- ing on the importance of early diagnosis using clinical exami- nations coupled with bitewings radiographs. This will enable the lesion to be caught at a very early stage, for it to be sealed in using a SSC utilizing the Hall technique. The crown could be fitted with minimal inconven- ience to the child patient in a child friendly way. This will ne- gate the need for LA injection, rubber dam, drilling the caries out. The reader is asked to com- pare Figure 3(c & d) to Figures 10 (a & b); one patient had multi- ple injections while the other did not have any for the SSC place- ments). The bite may be opened slightly following placement of a Hall SSC, but it corrects itself rapidly in children due to dento- alveolar compensation. While the conventional restora- tive approach is part and par- cel of the skills of a specialist in paediatric dentistry, the Hall technique must become part of the armamentarium in the fight against dental decay; a “tool” in the dentists “toolbox”. One of the Hall techniques unique features is that it can be used in general dental practice by GDPs, where most the children are treated. The Hall technique’s manual showing the technique step by step is available online to be downloaded for free for those dentists who would like to use it in their practice (24). Acknowledgement: The author would like to thank the patients and carers who consented to the use of the photos shown in this article. References 1) World Health Organiza- tion http://www.who.int/oral_ health/action/information/sur- veillance/en/ 2) El-Nadeef MAI, Hassab H and Al-Hosani E. National survey of the oral health of 5-year-old chil- dren in the United Arab Emir- ates. East Med H J (2010), Vol. 16 , No. 1; 51-55 3) Wendt LK, Hallonsten AL and Koch G. Oral health in pre-school children living in Sweden. Part III--A longitudi- nal study. Risk analyses based on caries prevalence at 3 years of age and immigrant status. Swedish Dental Journal (1999), 23(1):17-25 4) Hugoson A, Koch G, Hel- kimo AN and Lundin SÅ. Car- ies prevalence and distribution in individuals aged 3–20 years in Jonkoping, Sweden, over a 30-year period (1973–2003). In- ternational Journal of Paediat- ric Dentistry, vol. 18, no. 1, pp. 18–26, 2008. 5) Oral health survey of three- year-old children 2013. A report ontheprevalenceandseverityof dental decay. Public Health Eng- land. Available online @ http:// www.nwph.net/dentalhealth/ reports/DPHEP%20for%20Eng- land%20OH%20Survey%20 3yr%202013%20Report.pdf 6) Rodd, HD, Waterhouse PJ, Fuks AB, Fayle SA, Moffat MA. UK National Clinical Guidelines in Paediatric Dentistry: Pulp therapy for primary molars. In- ternational Journal of Paediatric Dentistry 16 (Suppl. 1): 15–23. 2006 7) Kindelan SA, Day, P, Nichol P, Willmott N, Fayle SA. National Clinical Guidelines in Paedi- atric Dentistry: Stainless steel preformed crowns for primary molars. International Journal of Paediatric Dentistry 2008; 18 (Suppl. 1) : 20–28s 8) Innes NP, Evans DJP and Stir- rups DR. The Hall Technique; a randomized controlled clinical trial of a novel method of man- aging carious primary molars in general dental practice: accept- ability of the technique and out- comes at 23 months. BMC Oral Health 2007, 7:18. Available on- line @ http://www.biomedcen- tral.com/1472-6831/7/18 9) Innes NP, Evans DJP and Stir- rups DR. Sealing Caries in Pri- mary Molars: Randomized Con- trol Trial, 5-year Results. J Dent Res 90(12):1405-1410, 2011 10) Kidd, E. Should Deciduous Teeth be Restored? Reflections of a Cariologist. Dent Update 2012; 39: 159–166. 11) Evans, DJP, Southwick, CAP, Foley, JI, Innes, NP, Pavitt, SH, and Hall, N. The Hall technique: a pilot trial of a novel use of pre- formed metal crowns for man- aging carious primary teeth. Tuith Online, December 2000. Available online @ http://www. dundee.ac.uk/tuith/Articles/ rt03.htm 12) Roberts, RF and Attari N. The wide gulf. Letter to the BDJ, June 2006 13) Santamaria RM, Innes NPT, Machiulskiene V, Evans DJP and Splieth CH. Caries Man- agement Strategies for Primary Molars: 1-Yr Randomized Con- trol Trial Results.(accepted for publication in Journal of Dental Research 2014) 14) Santamaria RM, Innes NPT, Machiulskiene V, Evans DJP and Splieth CH Acceptability of different caries management methods for primary molars in a RCT. (Accepted for publication in the International Journal Pae- diatric Dentistry in 2014) 15) The Magazine of the Ameri- can Academy of Pediatric Den- tistry Online. http://www.pedi- atricdentistrytoday.org/2013/ September/XLIX/5/news/arti- cle/269/ 16) Hashim Nainar SM. Success of Hall Crown Questioned. Pedi- atr Dent 2012;34:103 17) Yalgnkaya Erdemci Z, Bur- gak Cehreli S, and Ebru Tirali R. Hall Versus Conventional Stain- less Steel Crown Techniques: In Vitro Investigation of Marginal Fit and Microleakage Using Three Different Luting Agents. Pediatr Dent 2014;36:286-90 18) Ludwig KH, Fontana M, Vin- son LA, Platt JP, Dean JD. The success of stainless steel crowns placed with the Hall technique: A retrospective study. JADA 2014; 145(12):1248-1253. 19) Innes, NP and Evans, DJP. Modern approaches to caries management of the primary dentition. British Dental Journal 2013; 214: 559-566 20) Foley, J. Short communi- cation: A pan-European com- parison of the management of carious primary molar teeth by postgraduates in paediatric den- tistry. Eur Arch Paed Dent. 13 (Issue 1). 2012. 21) Innes NP, Evans DJP, Hall N. The Hall Technique for Manag- ing Carious Primary Molars. Dent Update 2009; 36: 472–478. 22) So D, Evans, D, Borrie F, Roughley M, Lamont T, Keight- ley A, Gardner A, Hussein I, De Souza N, Blain K, Innes NP. Measurement Of Occlusal Equi- libration Following Hall Crown Placement; Pilot Study. Abstract submitted to the International Association of Dental Research in November 2014. 23) Curzon, M. Primary tooth metal Crowns. European Ar- chives of Paediatric Dentistry 11 (Issue 5). 2010 24) Evans, D & Innes N. The Hall Technique. A minimum inter- vention, child centred approach in managing the carious prima- ry molar. A user manual. Free downloadable online manual. Available online @ http://dentist- ry.dundee.ac.uk/sites/dentistry. dundee.ac.uk/files/3M_93C%20 HallTechGuide2191110.pdf Indications include: Class I lesion, non-cavitated, if patient unable to accept fissure sealant, or conventional restoration Class I lesion, cavitated, if patient unable to accept partial caries removal technique, or conventional restoration Class II lesions, cavitated or non-cavitated Contra-indications include Teeth with signs or symptoms of irreversible pulpitis, or dental sepsis (pulpal pathosis) Teeth with clinical or radiographic signs of pulpal exposure, or periradicular pathology Teeth with crowns so broken down with caries, they would normally be considered as unrestorable with conventional techniques Patients at risk of infective endocarditis Table 1. Indications and contra-indications of the Hall technique. Conclusion Dental caries is an epidemic disease of childhood. While prevention is of essence, in a society where dental caries is rampant, its treatment can be challenging especially in young children. The Hall technique for restoring the carious primary molar is a newly developed technique that is based on an old concept: deprive caries from sugar substrate and it will arrest. The carious lesion needs to be detected early enough before it causes pulpal symptoms, emphasizing on the importance of early diagnosis using clinical examinations coupled with bitewings radiographs. This will enable the lesion to be caught at a very early stage, for it to be sealed in using a SSC utilizing the Hall technique. The crown could be fitted with minimal inconvenience to the child patient in a child friendly way. This will negate the need for LA injection, rubber dam, drilling the caries out. The reader is asked to compare Figure 3(c & d) to Figures 10 (a & b); one patient had multiple injections while the other did not have any for the SSC placements). The bite may be opened slightly following placement of a Hall SSC, but it corrects itself rapidly in children due to dento-alveolar compensation. While the conventional restorative approach is part and parcel of the skills of a specialist in paediatric dentistry, the Hall technique must become part of the armamentarium in the fight against dental decay; a “tool” in the dentists “toolbox”. One of the Hall techniques unique features is that it can be used in general dental practice by GDPs, where most the children are treated. The Hall technique manual showing the technique step by step is available online to be downloaded for free for those dentists who would like to use it in their practice (24). Dr. Iyad Hussein DDS (Dam), MDentSci (Leeds), GDC Stat.Exam (London), MFDSRCPS(Glasg) Asst. Clinical Professor in Paedi- atric Dentistry GDC/UK Specialist in Paediatric Dentistry (No 77094) Dubai College of Dental Medi- cine (DCDM), Dubai Healthcare City, Dubai, UAE Email: iyad.hussein@dcdm.ac.ae Contact Information