Heal or Conceal
Judgment Time for the Hall Technique
Theodore P. Croll, DDS | Constance M. Killian, DMD | Richard J. Simonsen, DDS, MS
More than one year ago, we wrote our concerns about the Hall Technique,1 and none of the questions we raised have been addressed by advocates of the method. Our concerns were also outlined in a letter that was published in Pediatric Dentistry.2 Three responses to that letter continued to advocate for the technique,3-5 but none of them addressed the questions we raised about infectious disease considerations, ethics, morality, medico-legal implications, or financial aspects of managing children with the Hall method. Perhaps our questions have not been addressed because there are no good answers.
The Hall Technique can be summarized as follows:
A child with a caries lesion of a primary molar (Figure 1), using no anesthesia, is fitted with an oversized preformed stainless steel crown. None of the infected tooth structure is debrided, and the anatomical crown is not prepared in any way. The crown form is not crimped, contoured, finished, or polished in the traditional manner.6 The preformed crown is taken out of the box, filled with a glass-ionomer luting cement, compressed upon the tooth, and excess cement removed. That’s it. An extracted primary molar that had been restored with a stainless steel crown 7 years before is shown in the cross-section, along with a simulated sectioned carious Hall crown (Figure 2). The dentist is then paid, or suitable forms are filled out for third party remuneration. Because there is no unique procedure code for a non-fitted crown on an unprepared infected tooth, one can assume only that practitioners are using standard stainless steel crown coding.
One letter writer compared the non-treatment Hall approach to an indirect pulp cap.3 That idea ignores the effects of calcium ions on bacteria and dentinal and pulpal healing, and also gives no consideration to the major aspect of wound healing: debridement. What is the medical or dental model for concealing necrotic and infected tissue, rather than debriding it, to set the stage for healing? Another letter claimed we used hyperbole and vitriol in our writing about the Hall Technique4 and another accused us of not reading published research about the method.5 We have read the research and wonder why non-fitted stainless steel crowns would ever be compared to standard fillings, such as resin-based composites (RBC) or traditional glass-ionomer systems (GI) in primary molars. RBCs don’t have the biocompatibility of GIs, and GIs don’t have the wear resistance, fracture strengths, or erosion resistance of resin-modified glass-ionomer cements (RMGIs). The newer RMGIs7,8 have even better physical characteristics than those that performed so well in one retrospective study published in 2001.9
We also were accused of being stuck in traditional ways of thinking and not being able to accept new paradigms of clinical care.5 When it comes to innovation and advancement of clinical dentistry concepts for children, over the decades, one needs only to peruse the literature regarding preventive resin restorations, resin-bonded sealants, enamel microabrasion, GI systems for children and teens, and other nuances in adhesive restorative dentistry to judge whether we have been mired in the old ways of doing things.
We have not been bitter, and we have not exaggerated anything in our quest to settle the propriety of managing primary molar caries lesions by concealment, rather than healing.
Healthcare professionals are bound by ethical standards when caring for patients. This is especially true when presenting treatment plans to parents or caregivers because they have very little understanding of advantages of one procedure or material over another. They rely on and trust dentists’ recommendations. A discussion of alternative methods of treatment is part of the professional responsibility we have to our patients and their parents. Is it ethical to restore a tooth using the Hall Technique without disclosing and emphasizing that a caries infection remains? Is it ethical to charge a fee without clear acknowledgement that a procedure does not conform to the accepted standard for stainless steel crown placement? Science has yet to determine the status of bacteria entrapped beneath a non-fitted luted crown form. That assessment must be made, preferably by microbiologists, so dentists can be assured that children receiving Hall crowns are not at risk for local osseous or systemic spread of infection.
Finally, one can imagine the inevitability that some entrepreneurial firm will develop over-the-counter Hall crowns that can be placed at home by a non-professional (eg, parent). Already, there are temporary dental cements for sale at local pharmacies. If the Hall Technique really requires no professional expertise for placement (no local anesthesia, no tooth preparation, no crown manipulation to perfect the fit), diagnosis and treatment of dental disease for some children could shift from the dental office to the family kitchen. We can do better than the Hall Technique for our patients.
Final Thoughts
We are calling on the leaders of organized dentistry to convene a panel of experts with the purpose of reviewing published research on the Hall Technique and judging whether retention of an oversized, ill-fitting stainless steel crown or the fact that the tooth has not been extracted are acceptable measures of success in research protocol. When the carious wound is not debrided, and appropriate treatment to accommodate pulp healing is not achieved, the tooth remains infected underneath the crown and the child is still sick. We do not understand why biological healing of tissue is not the chief measure of success in such research. Members of this panel should include experts in bioethics, medicolegal affairs, infectious disease, microbiology, histopathology, oral medicine, and recognized academic and clinical dental scholars in the specialties of pediatric dentistry, oral and maxillofacial pathology, oral and maxillofacial radiology, and endodontics. It is also important that administrators representing third party payers should be included. Findings and conclusions of this expert committee should be disseminated among pediatric dentists and general dentists treating children, so all implications of the Hall Technique will be known and the propriety of using it in children will be settled.
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. Letter to the editor. Pediatr Dent. 2016;38(2):101.
3. Hirsch J. Letter to the editor. Pediatr Dent. 2016;38(3):188.
4. Dean JA. Response to the letter to the editor. Pediatr Dent. 2016;38(3):190.
5. Innes N, Santamaria R, Duggal M, Splieth C. Letter to the editor. Pediatr Dent. 2016;38(4):278-279.
6. Croll TP. Preformed posterior stainless steel crowns: an update. Compend Contin Educ Dent. 1999;20(2):89-106.
7. Killian CM Croll TP. Nano-ionomer tooth repair in pediatric dentistry. Pediatr Dent. 2010;32(7):530-535.
8. Croll TP, Berg JH, Donly KJ. Dental repair material: a resin-modified glass-ionomer bioactive ionic resin-based composite. Compend Contin Educ Dent. 2015;36(1):602-607.
9. Croll TP, Bar-Zion Y, Segura A, Donly KJ. Clinical performance of resin-modified glass ionomer cement restorations in primary teeth. A restrospective evaluation. J Am Dent Assoc. 2001;132(8):1110-1116.
ABOUT THE AUTHORS
Theodore P. Croll, DDS, maintains a private pediatric dentistry practice in Doylestown, Pennsylvania. He is also an affiliate professor in the Department of Pediatric Dentistry at the University of Washington School of Dentistry in Seattle, Washington, and an adjunct professor of pediatric dentistry at the University of Texas Health Science Center at San Antonio Dental School in San Antonio, Texas.
Constance M. Killian, DMD, maintains a private pediatric dentistry practice in Doylestown, Pennsylvania. She is also an adjunct associate professor of pediatric dentistry at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania.
Richard J. Simonsen, DDS, MS, at the time of this writing, was Dean of the College of Dental Medicine at the University of Sharjah in the United Arab Emirates. He is the immediate past president of the American Academy of Esthetic Dentistry.
