Hall technique successful in comparative U.S. study

Stainless steel crowns placed using either a traditional preparation or the Hall technique have high and similar rates of survival, according to a new comparative U.S. study in the Journal of the American Dental Association (JADA, December 2014, Vol. 145:12, pp. 1248-1253).

The Hall technique, which is viewed as controversial by some practitioners, was pioneered by Norna Hall, BDS, a dentist working in a remote, rural part of Scotland where children had a high incidence of caries and families were reluctant to seek treatment. The technique involves placing a stainless steel crown over a primary molar tooth to seal the decay in, rather than the conventional method of removing the decay with a drill, then placing a filling. Starved of nutrients, the decay then stops or slows down. The crown stays in place until it falls out naturally with the tooth, at about age 10.

"I heard about this technique five years ago at an IADR [International Association for Dental Research] meeting and was intrigued by the concept," said study author Jeffrey A. Dean, DDS, the Ralph McDonald professor of pediatric dentistry and a professor of orthodontics at the Indiana University School of Dentistry, in an interview with DrBicuspid.com. "Even though I was surprised by the idea, I was impressed enough to think it might work."

After reading the relevant scientific literature, Dr. Dean decided to try the Hall technique in his own pediatric dental practice to hopefully avoid invasive techniques, passive restraint, and sedation on his young patients.

Dr. Dean was surprised at how simple and straightforward the technique was. He was able to use it effectively.

"Some of the concerns that have been raised about the Hall technique did not show up, and I went on using it in my practice," Dr. Dean said. "While dealing with children, no one likes long invasive procedures, so why would I use a technique that requires injections and takes longer when I can do this?"

"Some of my colleagues have chastised me, and I understand their reservations, because I had them too, but if we are to be practitioner-scientists, we need to keep an open mind to new ideas," he added.

Dr. Dean then asked a graduate student, Kevin Ludwig, DDS, who practices in South Bend, IN, to conduct a retrospective study. To his knowledge, this is the first U.S. study on this technique. While a lot of skepticism surrounds the Hall technique, Dr. Dean hopes that this study being published in the U.S. will help alleviate some of the concerns.

Successful management of dental caries in the pediatric population is a long-standing problem, Dr. Dean and colleagues noted in the JADA study. Behavioral problems can lead to children being refereed out to pediatric dentists, limiting access in areas that lack a pediatric dentist. Meanwhile, some children's uncooperative behavior may require the use of sedation or general anesthetic.

"The Hall technique is a conservative alternative treatment for carious primary molars," they wrote. "[It] provides dentists with a simple, definitive treatment that can be provided quickly to limit anxiety experienced by the patient."

The technique, however, remains experimental with limited data to support its use.

Evaluation

The researchers evaluated the success of stainless steel crowns used to restore caries lesions in primary molars placed using both the traditional and the Hall techniques. The retrospective chart review used patient records at Dr. Dean's private practice in Indiana between April 1, 2008, and April 1, 2013 (use of the Hall technique to place crowns started in 2010).

Inclusion criteria included caries lesion on a primary molar with no clinical or radiographic evidence of pulpitis, necrosis, or abscess; stainless steel crown placement as treatment; and a follow-up of six months or until failure, whichever came first.

From June 2010 through March 2013, 34 children received a total of 67 crowns placed using the Hall technique and were followed up for an average of 15 months, the authors noted. Meanwhile, 51 children received 117 crowns from March 2003 through December 2012 by means of traditional preparation and were followed up for an average of 53 months.

The majority of children in the Hall technique group were between ages 5 and 7, while the other group consisted of children ages 4 to 6.

The researchers graded restoration success by using a four-point scale based on presence or loss of the crown and whether the patient needed further treatment associated with pulpal pathology or secondary caries. They graded 97% (65) of the crowns placed with the Hall technique and 94% (110) placed with a tradition preparation as successful. Two Hall technique crowns and five traditional technique crowns failed as a result of abscesses or infection, while two traditional technique crowns experienced retention failure.

Although follow-up duration was different for both groups, a majority of failures for both techniques were experienced in the first two years, the authors noted.

"The results ... are in line with those of previous studies showing that the Hall technique can result in a clinically sound restoration," they wrote.

The authors pointed out that retrospective nature of the study as a limitation and stressed the need for a large prospective randomized controlled clinical trial to compare these two techniques.

"Pending prospective clinical trials, I have little doubt that this technique can become the standard of care," Dr. Dean said. "In my practice, the Hall technique is my standard approach unless there is some specific reason to use the traditional technique, like pulpal therapy, etc."

Dr. Dean concluded that like any retrospective study, theirs has its limitations. However, he is confident that they can find similar results with a prospective study.