82 MARCH 2020 // dentaltown.com by Dr. Jeanette MacLean

Dentaltown editorial advisory board member Jeanette MacLean, DDS, DABPD, FAAPD, is a board-certified pediatric dentist and private practice owner in Glendale, Arizona. MacLean has become an internationally recognized expert and advocate on the hot topic of minimally invasive dentistry, frequently lecturing across North America. Information: kidsteethandbraces.com

The Hall Technique A minimally invasive method of treating caries in pediatric patients

A shift to minimally an otherwise healthy, asymptomatic tooth. invasive treatment Instead, controlling the biofilm and placing It’s now known that caries is a biofilm a sealed restoration is preferred for caries disease, and carious lesions are the result management. This minimally invasive of a dysbiosis (an imbalance in the biofilm) approach is particularly advantageous for whereby net demineralization exceeds remin- young, apprehensive patients, who may eralization—and surgical intervention alone otherwise require sedation for traditional does not stop the disease process. surgical interventions. An evidence-based, Systematic reviews and meta-analyses minimally invasive treatment option for demonstrate that complete caries removal the management of severe early childhood is not necessary for caries management in caries is the Hall technique.

dentaltown.com \\ MARCH 2020 83 This minimally invasive approach is particularly advantageous for young, apprehensive patients, who may otherwise require sedation for traditional surgical interventions.

The Hall technique the Hall technique has an added benefit Informed consent is reviewed with the Dr. Norna Hall was a general practice in that it eliminates the need for shots and patient’s mother and treatment options dentist working in a region with a high drills, which could require sedation for were discussed, including no treatment; level of caries in Scotland. In 1997, an audit their child to tolerate the treatment. With silver diamine fluoride; extraction; or a discovered she was placing stainless steel proper informed consent, I have found the prefabricated stainless steel crown, placed crowns at a higher-than-average rate. Hall technique is well accepted by parents and with either traditional surgical preparation also was placing them in an unconventional well tolerated by patients. or the noninvasive Hall technique. way—without local anesthesia or tooth The patient’s mother opted for the Hall preparation, simply sealing the carious Contraindications technique because it would involve minimal lesions under the crown with a glass ionomer • Clinical symptoms of irreversible tooth preparation and no need for local cement, thereby cutting them off from their pulpitis or dental abscess. anesthetic or sedation. “fuel” (i.e., dietary carbohydrates) and • No clear band of dentin between arresting them. the carious lesion and the pulp. The technique To her surprise and delight, the clinical • Radiographic evidence of pulpal 1. Place orthodontic separators into the outcomes were similar to conventional exposure or periradicular pathology. mesial and distal contacts to create crown placement and well accepted by • Unrestorable, inadequate tooth space for the crown. You may use her patient population.1 And so the Hall structure for crown retention. orthodontic pliers, or thread two technique was born. Since that time, four • Children whose airway cannot pieces of floss through the separator, randomized control trials have been pub- be managed safely. pull them in opposite directions to lished that demonstrate the efficacy of the stretch the band, and then slide it Hall technique for caries management in Benefits into the contact. If the patient has pediatric patients.2–5 • Patient-centered care. open contacts or primate space, • Quicker to complete. it may not be necessary to place Presenting to the parent • Proven efficacy by randomized separators (Figs. 2a–2d). When introducing the option of the control trials. 2. After approximately two days to one Hall technique to a parent, I say this: “What • Minimal intervention is favorable week, remove the separators and clean would happen to you if I dropped you in a to the pulp. gross debris with plain pumice, then tank of cement? Would you live or would • Reduced anxiety/stress for the child rinse (Figs. 3a, 3b and 4). you die?” I usually get a look of wide eyes, patient, parent and dentist. 3. Protect the patient’s airway by followed by a laugh, then a response, “Die.” • No need for local anesthetic or positioning the child slightly upward, To which I reply, “Correct. So, when tooth preparation. drape a 4x4 gauze across the back of I seal the cavities’ bugs under a crown in • No soft-tissue damage. the throat, and/or use a rolled piece of cement, they’re also starved of the fuel • No accidental lip or tongue biting. adhesive medical tape to adhere the needed to survive, and they arrest and die.” SSC to your gloved finger. I also explain that the efficacy for the Case presentation 4. Select the crown and crimp or Hall technique is equivalent to the traditional A 5-year-old girl presents with extensive adjust as needed to have a “snap” surgical, i.e., drill-and-fill approach, each yet asymptomatic caries in her mandibular fit and good marginal adaptation with a small margin of failure.6 However, left first primary molar (Fig. 1). (Figs. 5a–c).

84 MARCH 2020 // dentaltown.com Fig. 1: Asymptomatic severe early childhood caries.

Fig. 4: Clean the tooth with plain pumice.

Figs. 2a–2d: Orthodontic separators are placed into contacts with pliers or floss.

Figs. 5a–5c: Select the appropriate size crown and try it on while Figs. 3a and 3b: After approximately two days to one week, the orthodontic protecting the patient’s airway using separator(s) are removed, and you may see the space that has been either gauze or medical tape, or having created between the teeth. the child seated slightly upright.

dentaltown.com \\ MARCH 2020 85 Fig. 9: Notice the bite is lightly open immediately postop.

Figs. 6a–6c: Fill the crown with a glass ionomer cement or resin-modified glass ionomer cement such as FujiCem2 or new FujiCem Evolve, which has the advantage of an automix tip and may be tack-cured for zirconia crowns.

Fig. 7: Seat the crown with firm finger pressure and have the patient bite down. Figs. 10a–10c: Two weeks postoperative. Notice the healthy gingival tissue and the bite has self- Figs. 8a and 8b: Clean off the excess cement by corrected. flossing and rinsing.

Learn more minimally invasive treatments Head to dentaltown.com/CE to find Dr. MacLean’s latest course, “Less Is More: Minimally Invasive Cosmetic Treatment Options for Enamel Defects.”

86 MARCH 2020 // dentaltown.com The parents of this 5-year-old patient traveled 2,500 miles from the Northern Territory of Canada Because the Hall so Dr. Jeanette MacLean could technique is usually treat him with the Hall technique in performed on molars, This patient has Hall Arizona, in lieu of general anesthesia. the stainless steel crowns on all four first crowns are not a big deal primary molars. aesthetically—this patient has two in place.

5. Fill the crown with a high-quality “The failure to follow new option for managing severe early childhood glass ionomer or resin-modified glass evidence is not limited to dentists caries. This minimally invasive approach ionomer cement (Figs. 6a–6c). who are ‘out of touch,’ do not allows the provider to increase access to care 6. Seat the crown with firm finger undertake continuing professional and improve the patient experience while pressure, or use a bite stick and have development, or have been prac- reducing cost and risk. n the patient help by biting down ticing for many years; in some firmly on a cotton roll (Fig. 7). countries and some schools, new References: 7. Clean the excess cement with wet 1. Innes NP, et al. The Hall Technique 10 years on: Questions dentists are still taught to remove and answers. Br Dent J. 2017 Mar 24;222(6):478-483. gauze, water spray and flossing the doi: 10.1038/sj.bdj.2017.273. all infected carious tissue, and 2. Innes N P, Evans D J P, Stirrups DR. Sealing caries in contacts (Figs. 8a and 8b). it is actually not possible to pass primary molars; randomized control trial, 5 year results. J 8. The patient’s bite may be slightly Dent Res 2011; 90: 1405-1410. professional examinations without 3. Santamaria R M, Innes N P T, Machiulskiene V, Evans D opened by approximately 1mm and J P, Splieth C H. Caries management strategies for primary demonstrating this. The reasons molars: 1yr randomized control trial results. J Dent Res will self-adjust over the next one 2014; 93: 1062–1069. to two weeks via intrusion of the underlying this failure to translate 4. Narbutaite J, Maciulskiene V, Splieth C H, Innes N P T, Santamaria R M. Acceptability of three different caries crowned tooth and opposing tooth, as evidence into clinical practice are treatment methods for primary molars among Lithuanian well as supereruption of the adjacent many and complex. children. 12th Congress of the European Academy of Paediat- ric Dentistry ‘A passion for Paediatric Dentistry’ teeth7–8 (Figs. 9 and 10a–10c). “The ‘don’t know’ could be 5. Araujo MP, Olegario IC, Hesse D, Innes NP, Bonifacio CC, Raggio DP. ART versus Hall Technique in Primary due to general ignorance (perhaps Molars: 1-Year Survival and Cost Analysis of a RCT The controversy ORCA Abstract number 86. Caries Res 2017;51:330 DOI: remedied with an appropriate 10.1159/000471777 There remains some controversy educational intervention) or the 6. Ludvig KH, Fontana M, Vinson L A, Platt J A, Dean J regarding this technique in the U.S., A. The success of stainless steel crowns placed with the Hall more problematic willful igno- Technique. JADA 2014; 145: 1248-1253. often stemming from lack of awareness 7. Van der Zee V, van Amerongen W E. Influence of preformed rance, where the subject chooses metal crowns (Hall Technique) on the occlusal vertical of the randomized control trial evidence not to learn more about a topic dimension in the primary dentition. Eur Arch Pediatr Dent for Hall crowns or the systematic reviews 2010; 11: 225-227. (perhaps because it challenges his 8. So D, Evans D J P, Borrie F et al, Measurement of Occlusal and meta-analyses that have demonstrated Equilibration Following Hall Crown Placement. J Dent or her current beliefs).” 11 Res 2015; 94 (Spec Iss A). Abstract No 0080; 2015. IADR, that complete caries removal is not neces- Boston, US. sary for caries management.9–10 Members 9. Thompson V., et al. Treatment of deep carious lesions by complete excavation or partial removal: a critical review. J of the International Caries Consensus The big picture Am Dent Assoc. 2008 Jun;139(6):705-12. 10. Ricketts D., et al. Operative caries management in adults and Collaboration, Drs. Innes, Frencken and While the Hall technique is not for every children. Cochrane Database Syst Rev. 2013 Mar 28;(3). Schwendicke, summed it up best in their patient nor every tooth, it is an evidence-based 11. Innes N., et al. Don’t Know, Can’t Do, Won’t Change: Barriers to Moving Knowledge to Action in Managing the

2016 article: procedure that is an extremely advantageous Carious Lesion. J Dent Res 2016; May;95(5):485-6.

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