Modern concepts for caries management aim to avoid invasive procedures whenever possible, and instead control the activity of the biofilm and lesions. When a caries lesion remains sealed from cariogenic biofilm, the prognosis is good for it to arrest, and odontoblasts form reparative dentin further protecting the pulp. The Hall Technique (HT) is one such method of sealing cariogenic lesions in primary molars within a preformed metal crown (PMC) without removal of tooth structure.ii Multiple randomized control trials and systematic reviews have demonstrated the efficacy of HT for the restoration of primary teeth, with clinical outcomes similar to or better than conventional restorations.iii,iv,v,vi,vii,viii,ix,x,xi,xii,xiii HT is well tolerated by the majority of children and acceptable to their parents.xii HT is particularly advantageous for young, apprehensive patients, who may otherwise require sedation for traditional surgical interventions.
The American Dental Association released an evidence-based clinical practice guideline on restorative treatments for caries lesions in July of 2023 which shed light on the benefits of more conservative caries removal approaches in vital teeth.xiv A key finding for advanced lesions was that more conservative caries tissue removal (CTR) approaches were associated with fewer clinical failures. The ADA restorative guideline supports selective, step-wise, and no CTR in vital primary teeth with moderate and advanced caries lesions, including PMCs placed utilizing HT.
While considered standard of care in the United Kingdom for more than a decade, HT was initially met with harsh criticism in the United States. Various editorial-style articles lashed out at this nonsurgical approach, demonstrating that the HT critics were likely unaware of the body of clinical evidence to support its efficacy.xv,xvi The COVID19 pandemic became a tipping point for awareness and adoption of HT in the US thanks to it being a non-aerosol treatment option, the serendipitous timing of pro-HT content, and virtual continuing education courses on HT viewed by thousands of providers during forced clinic closures to non-urgent care.xvii US based pediatric residency programs are increasing the teaching and utilization of nonsurgical caries management techniques. A 2020 survey of pediatric dentistry residency program directors revealed that 90.2% were teaching Hall Technique didactically and 69.1% were utilizing it clinically, in striking contrast to a 2015 version of the survey which did not include HT.xviii
While HT does not require administration of local anesthetic or removal of tooth structure, it does require proper case selection, accurate pulpal assessment, excellent behavior management skills, and careful selection, sizing, and placement of the PMC. As with any restorative procedure, HT should be part of a comprehensive and continuous caries prevention and management care plan.
With the new ADA restorative guidelines, evolving pre and postdoctoral dental curriculums, increasing awareness through continuing education and dental literature, HT will likely continue to increase in adoption and utilization among US dental practitioners. For pediatric patients and our strained Medicaid system, HT will help improve oral health, improve clinical outcomes, improve the patient experience, increase access to care, and reduce treatment cost. Hall Technique is a welcome addition to our restorative repertoire.
Dr. Jeanette MacLean is a board certified pediatric dentist, speaker, and private practice owner of Affiliated Children’s Dental Specialists in Glendale, AZ. Kidsteethandbraces.com
iSchwendicke F. Contemporary concepts in carious tissue removal: A review. J Esthet Restor Dent. 2017 Nov 12;29(6):403-408.
iiInnes NP, Evans DJ, Bonifacio CC, Geneser M, Hesse D, Heimer M, Kanellis M, Machiulskiene V, Narbutaité J, Olegário IC, Owais A, Araujo MP, Raggio DP, Splieth C, van Amerongen E, Weber-Gasparoni K, Santamaria RM. The Hall Technique 10 years on: Questions and answers. Br Dent J. 2017 Mar 24;222(6):478-483.
iiiInnes N P, Evans D J P, Stirrups DR. Sealing caries in primary molars; randomized control trial, 5 year results. J Dent Res 2011; 90: 1405-1410.
ivSantamaria R M, Innes N P T, Machiulskiene V, Evans D J P, Splieth C H. Caries management strategies for primary molars: 1yr randomized control trial results. J Dent Res 2014; 93: 1062–1069.
vNarbutaite J, Maciulskiene V, Splieth C H, Innes N P T, Santamaria R M. Acceptability of three different caries treatment methods for primary molars among Lithuanian children. 12th Congress of the European Academy of Paediatric Dentistry ‘A passion for Paediatric Dentistry’
viAraujo MP, Olegario IC, Hesse D, Innes NP, Bonifacio CC, Raggio DP. ART versus Hall Technique in Primary Molars: 1-Year Survival and Cost Analysis of a RCT ORCA Abstract number 86. Caries Res 2017;51:330
viiBadar SB, Tabassum S, Khan FR, Ghafoor R. Effectiveness of Hall Technique for Primary Carious Molars: A Systematic Review and Meta-analysis. Int J Clin Pediatr Dent. 2019 Sep-Oct;12(5):445-452.
viiiHu S, BaniHani A, Nevitt S, Maden M, Santamaria RM, Albadri S. Hall technique for primary teeth: A systematic review and meta-analysis. Jpn Dent Sci Rev. 2022 Nov;58:286-297.
ixKaptan A, Korkmaz E. Evaluation of success of stainless steel crowns placed using the hall technique in children with high caries risk: A randomized clinical trial. Niger J Clin Pract. 2021 Mar;24(3):425-434.
xElamin F, Abdelazeem N, Salah I, Mirghani Y, Wong F. A randomized clinical trial comparing Hall vs conventional technique in placing preformed metal crowns from Sudan. PLoS One. 2019 Jun 3;14(6):e0217740.
xiAyedun OS, Oredugba FA, Sote EO. Comparison of the treatment outcomes of the conventional stainless steel crown restorations and the hall technique in the treatment of carious primary molars. Niger J Clin Pract. 2021 Apr;24(4):584-594.
xiiEbrahimi M, Shirazi AS, Afshari E. Success and Behavior During Atraumatic Restorative Treatment, the Hall Technique, and the Stainless Steel Crown Technique for Primary Molar Teeth. Pediatr Dent. 2020 May 15;42(3):187-192.
xiiiBoyd DH, Thomson WM, Leon de la Barra S, Fuge KN, van den Heever R, Butler BM, Leov F, Foster Page LA. A Primary Care Randomized Controlled Trial of Hall and Conventional Restorative Techniques. JDR Clin Trans Res. 2021 Apr;6(2):205-212.
xivDhar V, Pilcher L, Fontana M, González-Cabezas C, Keels MA, Mascarenhas AK, Nascimento M, Platt JA, Sabino GJ, Slayton R, Tinanoff N, Young DA, Zero DT, Pahlke S, Urquhart O, O'Brien KK, Carrasco-Labra A. Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association. J Am Dent Assoc. 2023 Jul;154(7):551-566.
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xvCroll T, Killian C, Simonsen R. Heal or Conceal: Judgment Time for the Hall Technique. Inside Dentistry, February 2017, Vol. 13(2).
xviiMacLean J. The Hall Technique. Dentaltown, March 2020.
xviiiCrystal YO, Janal MN, Yim S, Nelson T. Teaching and utilization of silver diamine fluoride and Hall-style crowns in US pediatric dentistry residency programs. J Am Dent Assoc. 2020 Oct;151(10):755-763.
xixVan der Zee V, van Amerongen W E. Influence of preformed metal crowns (Hall Technique) on the occlusal vertical dimension in the primary dentition. Eur Arch Pediatr Dent 2010; 11: 225-227.
xxSo D, Evans D J P, Borrie F et al, Measurement of Occlusal Equilibration Following Hall Crown Placement. J Dent Res 2015; 94 (Spec Iss A). Abstract No 0080; 2015. IADR, Boston, US.
xxiNair K, Chikkanarasaiah N, Poovani S, Thumati P. Digital occlusal analysis of vertical dimension and maximum intercuspal position after placement of stainless steel crown using hall technique in children. Int J Paediatr Dent. 2020 Nov;30(6):805-815.