Out of Sight, Out of Mind
Examining the Hall technique through the lens of the ABPD’s core values
Theodore P. Croll, DDS | Constance M. Killian, DMD
In 2016, The American Academy of Pediatric Dentistry (AAPD) established a Safety Committee to protect the health and well-being of patients and their providers. On November 8, 2019, the AAPD will hold a 2-day safety symposium in Chicago, Illinois. After reading the online announcement for this event by Leila Younger, DDS, MS, president of the American Board of Pediatric Dentistry (ABPD), we were particularly heartened by her assertion that "Among the ABPDs core values is ‘the provision of the highest quality oral healthcare for children. Such care is thoughtful, careful, ethical, and based on the current scientific evidence.'"
These are marvelous words, and Hippocrates himself would probably be proud that such thinking was occurring in the healing professions. Younger concludes the announcement by saying, "Together, the AAPD and the ABPD hope to protect the well-being of providers, dental team members, our patients, and the families who trust us with their care."
If these worthy and splendid sentiments are to be taken seriously, we would like to call on the AAPD and ABPD to make a statement about the use of procedures and techniques, new and old, as they relate to patient safety. Although the concerns presented in this editorial should apply to all of the methods and materials used in clinical pediatric dentistry, our comments specifically address concerns related to the use of the Hall technique. The Hall method of dealing with carious primary teeth is gaining popularity in North America; however, when viewed through the lens of the ABPD's core values for pediatric care, we believe that it presents serious issues that should preclude its use in clinical practice.
Highest Quality
The Hall method is a clinical technique that conceals a child's dental bacterial infection from view but does not actually heal the child. The clinician collects a fee for this activity, which can hardly be called "treatment," and the infection remains until the child sheds the tooth. For many clinicians, it is difficult to understand how a treatment that leaves a patient in a diseased state could ever be considered "the highest quality oral healthcare."
Thoughtful
The Hall technique cannot be regarded as very thoughtful because it is easy to shove an oversized, nonadapted, cement-filled steel crown form over a carious tooth and have the patient bite it into "occlusion." In many cases that have been described, no preoperative radiograph was recorded, so there was little information about or regard for the pulpal health of the tooth being treated. Indirect pulp therapy, the so-called rationalization of the Hall technique, calls for the removal of most of the carious tooth substance, leaving only a thin layer of infected dentin in close approximation to the pulp. The remaining infected dentin is then covered with a calcium-containing material, such as a calcium silicate/mineral trioxide aggregate, for healing purposes, which is then covered by the appropriate restorative material. When the Hall technique is performed, how much debris is left under the crown form? How high is the bacterial load? We cannot even give an intelligent guess. Is judicious debridement not the first stage in wound healing? How can a dentist who claims to be a healer do this to a child without even making a complete initial diagnosis? Is this technique being used on children who are immunocompromised or who are in need of subacute bacterial endocarditis prophylaxis? Where is the thoughtfulness in this incomplete diagnosis and treatment planning?
Careful
Pediatric dentistry textbooks and many scholarly teachers of operative dentistry advocate for the use of a rubber dam during the provision of all restorative dentistry for children. However, the Hall technique is largely performed without local anesthesia and without a rubber dam. Given the known challenges associated with the behavior of young children, there is obviously a possibility of the crown being swallowed or aspirated. Without a focus on safety, how can this method be considered careful?
Ethical
When the Hall technique is presented, are all parents and caregivers given complete explanations, and do they understand the nature of the method? Do they understand that active tooth decay remains in the tooth and that nothing has been done to promote healing? Do they fully comprehend that the dentist justifying the method believes with no scientific proof or justification that the live bacteria under the unadjusted stainless steel crown form will somehow be deprived of nutrients? Parents and caregivers deserve complete disclosure of how this technique deviates from standard clinical restorative dentistry norms so that they can make fully informed decisions regarding whether the dentist should actually aim to heal the tooth or merely conceal the bacterial infection.
Many practitioners admit that they perform the Hall technique and then charge their usual fee for a stainless steel crown. Some are silent about this because they know that taking remuneration from parents, caregivers, or third-party sources for "nontreatment" could surely be deemed unethical, but they do it anyway. The Hall technique, at best, should be considered only as a means to provide interim or palliative care, and since the advent of silver diammine fluoride in North America in 2015, it is even difficult to consider Hall crowns for that role. It is clearly unethical to accept payment for a procedure that a patient believes is healing his or her tooth when the caries infection remains, and the tooth and the patient are still sick after crown malplacement.
Are Hall crowns being pushed into place when a child is being treated under general anesthesia? In some cases, we know that they are. How would Hall proponents explain to a curious anesthesiologist and operating room team that dentists can now leave active caries infections in place and simply cement crowns to conceal the lesions? "Out of sight, out of mind" has no place in restorative dentistry or in any type of wound healing for that matter. Might dentists ultimately use this convoluted rationale to treat certain cases involving permanent teeth? All clinicians should have ethical concerns regarding these issues.
Evidence-Based
In 2015 and 2017, we presented concerns about the Hall technique and its misleading research, and still, advocates of the method have failed to respond to and address the questions and concerns that have been posed.1,2Reports of Hall crown "success" are based on the fact that the stainless steel crown is merely still present on the tooth at certain time intervals after placement. The crown is still present? What about healing? When did pediatric dentistry cease to be a healing profession and become one of concealing infections so they simply cannot be seen? To consider calling such treatment "evidence-based" is illogical and misleading. Recent studies tout the long-term success of Hall crowns when compared with other restorations, but the following question remains unaddressed by Hall advocates: How do we know scientifically that leaving a caries infection in a primary tooth under a cement "seal" will truly heal the tooth and make for a healthy child? We support new techniques, new materials, new applications, and new paradigms for treatment, but these must be based on scientific principles and logic. True scholarly research is needed before there can be acceptance and adoption of a method that appears devoid of the basic principles and proven results of healing.
A Call to Action
We hope that the leaders of the AAPD and the ABPD will consider this editorial and study all of the legitimate concerns about the Hall technique with the Safety Committee. It is way past the time that the AAPD, ABPD, and American Dental Association should take a stand on whether using the Hall technique on our youngest patients represents oral healthcare that is high quality, thoughtful, careful, ethical, and based on genuine current scientific evidence.
About the Authors
Theodore P. Croll, DDS, is the clinical director of Cavity Busters LLC in Doylestown, Pennsylvania; an adjunct professor of pediatric dentistry at the University of Texas Health Science Center at San Antonio in San Antonio, Texas; and a clinical professor of pediatric dentistry at the Case Western Reserve University School of Dental Medicine in Cleveland, Ohio.
Constance M. Killian, DMD, is an adjunct associate professor of pediatric dentistry at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, and she maintains a private practice in Doylestown, Pennsylvania.
References
1. Croll TP, Killian CM, Simonsen RJ. The Hall technique: serious questions remain. Inside Dentistry. 2015;
11(7):30-32.
2. Croll TP, Killian CM, Simonsen RJ. Heal or Conceal? Judgment time for the Hall technique. Inside Dentistry. 2017;13(2):20-21.
