GENERAL

The Hall Technique 10 years on: Questions and answers

N. P. T. Innes,*1 D. J. P. Evans,1 C. C. Bonifacio,2 M. Geneser,3 D. Hesse,2 M. Heimer,1 M. Kanellis,3 V. Machiulskiene,4
J. Narbutaité,4 I. C. Olegário,5 A. Owais,3 M. P. Araujo,5 D. P. Raggio,5 C. Splieth,6 E. van Amerongen,2
K. Weber-Gasparoni3 and R. M. Santamaria6

InInbrief
brief
Discusses the development and acceptance of the Provides information on where to find out more Reports an overview of high quality evidence from
Hall Technique. about the Hall Technique. randomised control trials supporting use of the Hall
Technique in day to day practice.

It is ten years since the first paper on the Hall Technique was published in the British Dental Journal and almost 20 years since
the technique first came to notice. Dr Norna Hall a (now retired) general dental practitioner from the north of Scotland had,
for many years, been managing carious primary molar teeth by cementing preformed metal crowns over them, with no local
anaesthesia, tooth preparation or carious tissue removal. This first report, a retrospective analysis of Dr Hall’s treatments, caused
controversy. How could simply sealing a carious lesion, with all the associated bacteria and decayed tissues, possibly be clinically
successful? Since then, growing understanding that caries is essentially a biofilm driven disease rather than an infectious
disease, explains why the Hall Technique, and other ‘sealing in’ carious lesion techniques, are successful. The intervening
ten years has seen robust evidence from several randomised control trials that are either completed or underway. These have
found the Hall Technique superior to comparator treatments, with success rates (no pain or infection) of 99% (UK study)
and 100% (Germany) at one year, 98% and 93% over two years (UK and Germany) and 97% over five years (UK). The Hall
Technique is now regarded as one of several biological management options for carious lesions in primary molars. This paper
covers commonly asked questions about the Hall Technique and speculates on what lies ahead.

Questions Although conventional preformed crowns are usage of crowns was reported in hypothetical
used to carry out the Hall Technique, and it is case treatment plans, even amongst paediatric
What is the Hall Technique? simply a different way of using these crowns, dentistry specialists. Tran stated that, ‘Mastery
The Hall Technique is a method for using crowns fitted this way are usually referred to of the crown continues to elude thousands of
preformed metal (also known as stainless steel) simply as Hall crowns. More information can graduating dentists every year who, as a result
crowns to manage carious primary molar teeth, be found on Wikipedia (https://en.wikipedia. of their discomfort, shy away from it and rely
by seating a correctly sized crown over the org/wiki/Hall_Technique, as of 6 March 2017), on huge amalgams to restore primary teeth.’2
tooth and sealing the carious lesion in, using a where there is also a downloadable illustrated During an audit of paediatric dental service
glass ionomer luting cement. Local anaesthesia PDF manual explaining when to, and how to, provision in the north east of Scotland in 1997,
is not required, tooth preparation is not carried carry out the technique from the correspond- one general dental practitioner, Dr Norna Hall
out, and no carious tissue is removed (Fig. 1). ing author. Table  1 lists the indications and (hence the name the Hall Technique) was
contraindications for the Hall Technique. found to be the only dentist, out of 150 in the
regional audit, regularly placing preformed
1
School of Dentistry, University of Dundee, Dundee, United
Kingdom; 2Department of Cariology, Pedodontology
How did the Hall Technique come crowns in children. During discussion, it
and Endodontology, Amsterdam, Netherlands; 3College about and when did it start being became apparent that Dr Hall was using the
of Dentistry, Iowa City, Iowa, United States; 4Faculty of
Odontology, Lithuanian University of Health Sciences,
used? crowns in an unconventional way – not placing
Eiveniu 2, Kaunas, Lithuania; 5Dental School, Sao Paolo, In the mid-1990s, it was generally accepted local anaesthesia, removing caries or preparing
Brazil; 6Zahnmedizin & Kinderzahnheilkunde, Greifswald,
Germany
that crowns were the most predictable res- the tooth. Dr Hall worked in an area with high
*Correspondence to: Professor Nicola Innes toration for primary molars, rarely failing. levels of caries and low treatment acceptance.
Email: [email protected]
However, in 1996 in Scotland, a total of only She had gradually adapted conventional crown
Refereed Paper. Accepted 7 February 2017 164 crowns were fitted.1 There is some evidence placement to this technique in an attempt to
DOI: 10.1038/sj.bdj.2017.273 that this is not a dissimilar situation from other respond to the demand for treatment that was
©
British Dental Journal 2017; 222: 478-483
countries. In Australia in 2003, a relatively low quick, and did not involve local anaesthesia.

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 GENERAL

Fig. 1 Series of three photographs showing a crown being fitted to tooth 84 (lower right 1st primary molar). a) Different crowns are tried
over the tooth until the correct size is found (covering the cusps and giving a feeling of ‘spring back’. Note that gauze is being used for
airway protection. b) The crown is filled with glass ionomer cement. c) The crown is seated over the tooth (there is no local anaesthetic,
tooth preparation or caries removal) and, in this case, the child has used their bite force to seat the crown with cotton wool to help
distribute the force. The gingiva is blanching as the crown is sitting slightly subgingivally, further improving the seal and preventing the
lesion progressing. Same child as Fig. 3

She also found that both crown placement

techniques (conventional and Hall Technique) Table 1 Indications and contra-indications for (teeth) using the Hall Technique for
managing primary molars with caries lesions assessed as at risk of progressing and
gave similar outcomes and her population
causing pain/sepsis before exfoliation
found it comfortable and acceptable.3 From her
meticulously kept and detailed notes, we were Indications include Proximal lesions, cavitated or non-cavitated
teeth with: Occlusal lesions, non-cavitated if the child is unable to accept a fissure sealant
able to collect data and publish a retrospective Occlusal lesions, cavitated if the child is unable to accept selective caries removal
analysis on the survival of the teeth she had
Contra-indications Where no ‘clear band of dentine’ can be seen on a radiograph
been treating that way (now ten years ago) in include teeth with: Signs or symptoms of irreversible pulpitis, or dental infection (sepsis)
the British Dental Journal.4 Clinical or radiographic signs of pulpal exposure, or periradicular pathology
Crowns/teeth so broken down they would be unrestorable with conventional techniques
Children where the airway cannot be managed safely
How can sealing caries into a tooth
be successful?
A Hall Crown is a predictably successful growing understanding that dental caries is a does not have to involve surgical eradication of
restoration. When a carious lesion is sealed biofilm-driven disease resulting from a change the biofilm, carious tooth tissue and all plaque
into a tooth, the biofilm (the community of in the relationship between our bacterial guests bacteria to stop the progress of the disease.
microbes, their products and extracellular (who generally prevent pathogens from colo- Instead, maintaining a non-cariogenic biofilm,
polymeric matrix) is physically prevented from nising us) and ourselves, when our intake of continually removing the biofilm through
accessing nutrition from its main substrate, refined carbohydrate becomes excessive. This toothbrushing with fluoridated toothpaste and
dietary carbohydrate. This means that the excessive intake, when it occurs, forces a allowing tissue to remineralise, or moving a
actively carious/cariogenic lesion becomes a change from a healthy, symbiotic coexistance, cariogenic biofilm to a non-cariogenic state
non-cariogenic lesion. Like other treatments to a dysbiotic, imbalanced association.6,7 When will all be successful in preventing the ongoing
aimed at managing carious lesions by sealing environmental conditions change to reduce demineralisation of tooth tissue.
them in, a Hall crown works by depriving the microbial diversity and stability (for example Preformed metal crowns (regardless of method
lesion of fuel and making the environment with an increase in dietary sugar, favouring of placement) have consistently been shown to
unfavourable for its progression. The dental the proliferation of aciduric and acidogenic perform better than restorations for the man-
pulp lays down reparative dentine, effectively species), an imbalance occurs; increased acid agement of dental caries in primary teeth, and
retreating in response to the advancing carious production overwhelms the local reminer- this is because of the high quality seal that can
lesion. By sealing in the carious lesion, we are alisation systems, causing demineralisation predictably be achieved.9,10 The Hall Technique
essentially tipping the balance in this race in of tooth tissue, and a carious lesion forms. can essentially be thought of as an extension of
favour of the pulp, with the aim of arresting the There are many ways of controlling the the indirect pulp cap (where the pulp has carious
lesion before it advances far enough to cause demineralisation process, including (but not tissue left over it but is sealed in). This approach
irreversible inflammation of the dental pulp. It limited to): removing the biofilm; increasing relies on obtaining a good seal, and a crown
is worth exploring this change in our under- saliva (quantity and mineralisation potential); placed using the Hall Technique allows that
standing of dental caries as this underpins the adding fluoride; reducing sugar frequency good seal to be achieved, with a high degree of
Hall Technique and is at the heart of changes through diet change; and, of course, physically predictability. Whilst it is equally possible to seal
in our management strategies. blocking cariogenic biofilm from its substrate.8 a carious lesion into a tooth using a restorative
The oral biofilm is one of the most complex This is how fissure sealants and crowns placed material such as composites or glass ionomers,
biofilms of our human microbiome communi- using the Hall Technique work. it is more difficult, especially in a young child, to
ties, and in health, has biodiversity, balance and The clinical relevance of this is that once the achieve the same high quality of seal, especially
stability in its community members.5 There is a disease has become established, managing it in occluso-proximal cavities.

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 GENERAL

How well does it work?

Randomised control trials and controlled clinical
trials, either completed3,11 or underway,12–17 have
measured the acceptability and clinical success of
the Hall Technique. If we measure ‘success’ as a
lack of pain and infection (which is one of the key
goals in caring for the child with dental caries) then
the data show that after one year, placing a crown
in line with the recommended indications (https://
en.wikipedia.org/wiki/Hall_Technique – 2 March
2017), a high success rate even in proximal lesions
can be expected. These published randomised
control trials have found the Hall Technique as
good as, or better than, comparator treatments
with success rates (no pain or infection) of 99%
(UK trial)3,11 and 100% (Germany) at one year,13
98% over two years (UK 98% and Germany 93%)
and 97% over five years (UK).11 Figure 2 shows Fig. 2 Radiograph of a 5-year-old child showing tooth 85 (lower right 2nd primary molar) with
a radiograph of a tooth suitable for managing a mesial carious lesion and tooth 84 (lower right 1st primary molar) with a distal carious lesion
extending into dentine. The dentinal lesion is likely to be cavitated and needs to be managed.
with the Hall Technique, where there appears to
A ‘clear band of dentine’ is visible between the advancing edge of the lesion and the dental
be a radiodense zone or ‘clear band of dentine’ pulp and fitting a crown at this stage has a high chance of success
between the carious lesion and the dental pulp.
A retrospective analysis of 161 children attending
Dundee Dental Hospital found that when the clear The success rate of the Hall Technique is Low levels of child- and dentist-reported
band of dentine is used as an indication, there is consistently high, and as a treatment option, discomfort for the child during treatment pro-
over a 97% chance of success in treatment over an has been found to be preferred to conventional cedures have been reported when compared
average of 3 years (range 1-6 years).18 restorations by children and parents alike. For with conventional treatment,4,21,22 non-restor-
these reasons, it might be difficult to justify ative approaches and atraumatic restorative
How do crowns placed using the carrying out a direct comparison of full caries treatment. Also, children treated with the
Hall Technique compare with removal then conventionally placed crowns Hall Technique showed less negative behaviour
crowns placed using conventional with Hall crowns. Given the high success rate compared to children having conventional
techniques? and acceptability of the Hall Technique we treatment (using rotary instruments) and
There are no randomised control trials that should also begin to question why we would dentists considered it an easier, and quickerg,
directly compare Hall Technique-placed crowns treat a child more invasively than we need to. procedure.3,21
with conventionally-placed crowns. However, Why use local anaesthesia and dental drills The final appearance of a metal crown can
one retrospective study of a US paediatric (which although generally safe, can be poorly present a problem for some parents. In one UK
practitioner’s records has assessed success rates tolerated by some children, and in the case of study, when questioned about Hall crowns,
of conventional- and Hall Technique-placed the high speed handpiece, carry the risk of iat- objections to the appearance were reported by
crowns.19 Success was defined as no further rogenic damage to adjacent teeth), when there around 5% of parents.23 However, children do
treatment being required, the crown remaining is a less invasive option? not seem to mind the appearance and commonly
in place and no pulp pathology (assessed clini- report very positively on their crowns, referring
cally and radiographically). There was no sta- What do children and parents think of to them as their ‘special’, ‘shiny’, ‘space’ ‘princess’,
tistically significant difference between either the Hall Technique? ‘Iron Man’, ‘pirate’ or ‘star’ tooth.24
method for placing crowns. A total of 65 out of How well the Hall Technique is accepted by
67 Hall crowns (97%) were successful and 110 of children and parents are questions that are What happens to the occlusion
117 (94%) of conventionally-placed crowns were commonly asked. To try to answer these when a crown is fitted using the Hall
successful. Another US retrospective study,20 questions, patient-centred outcomes such Technique?
also found high clinical and radiographic as discomfort reported by the child, dentist One of the concerns with the Hall Technique
success for crowns placed on primary molars and parent have been investigated, as well has been the increase in the occluso-vertical
using the Hall Technique. At initial follow-up as acceptability of the technique to parents. dimension (OVD). Children do not seem to
(mean time  =  9.9 months), a success rate of Overall, these studies have found that, when be concerned about this increase and although
98.9% was observed both clinically (178 of 180 compared with other treatments, children they appear uncomfortable at first, they seem
crowns) and radiographically (86  of 87 with preferred the Hall Technique crown or rated to accommodate to the disruption in their
radiographs available). At the second follow-up it as similar to other treatments, and parents occlusion quite quickly. Several studies have
(mean time 20.1 months), 74 of 76 (97.4%) Hall preferred it to alternative treatments.3,21 Parents noted that this OVD increase (Fig. 3) resolves
crowns were clinically successful and 37 of 39 and dentists also rated the child’s behaviour as within a few weeks with no detriment21,25 and
(94.9%) were radiographically successful. positive when the Hall Technique was used.21 none have found any temporomandibular joint

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 GENERAL

pain even when parents have been specifically

asked about this issue.
In a prospective study of 10 children’s occlu-
sions following placement of a Hall crown being
fitted,26 clinical photographs, study model and
intra-oral measurement follow-ups were carried
out at two weeks, six weeks and six months.
There was a mean increase in the OVD of 1.1
mm immediately following crown placement.
This reduced to 0.3 mm after two weeks, with
the dentition appearing to have equilibrated to
its pre-crown state, and staying at this level. It
appeared that the compensation was mainly
(although not completely) from the intrusion
of the crowned tooth with some intrusion of the
opposing tooth. There is no evidence of damage
to the permanent successor.

Who uses the Hall Technique?

The Hall Technique is now being widely used
in Australia, Belgium, Brazil, Chile, Germany,
India, Netherlands, New Zealand, UAE, UK and
the US amongst others. The technique is now
taught in all dental schools throughout the UK,
New Zealand, in many across Europe, in many
graduate paediatric dentistry programmes in
the UK, US, Australia, India and some South
American and Middle East countries.
It is well accepted that transfer of any new Fig. 3 The same child as Fig. 1. Anterior view of the dentition a) before the crown fit and b) 10
healthcare intervention from research study days after the crowns were fitted to teeth 84 and 74 (right and left 1st primary molars). Note
to clinical practice can take many years. 27,28 that the occlusion has returned almost fully to its original state
This challenge of speeding up adoption of a
new treatment, once evidence has established in the United States was just 2.1 with a range of However, in order to cement a crown without
its effectiveness, is probably the greatest one 0–10.30 With such limited clinical experience any tooth preparation, the crown material must
we face. How do we encourage clinicians to in placing crowns it is easy to understand why have a certain plasticity and ductility, so that it
change their current practice and adopt new graduating dentists are more comfortable placing can pass over the most bulbous part of the tooth
techniques or perspectives? There has been a amalgams and composites. It has been docu- without fracturing or permanently deforming, a
great deal of controversy in the past over the mented in the literature that when evaluating the quality that the preformed metal crowns possess.
use of the Hall Technique with emotion, misin- same patient information and radiographs, general Ceramics are one of the most commonly used
formation and outdated ideas often being used dentists are more likely to recommend multi-sur- materials for indirect restorations. However, they
in arguments rather than logic, understanding face restorations for carious primary molars, while have low flexural strength values and fracture with
or evidence.29 However, it seems fair to say that paediatric dentists are more likely to recommend little or no plastic deformation. Unfortunately,
there is now little controversy over its effective- preformed metal crowns.31 This is unfortunate composite resins share this same property and
ness, and the fact that it should have a place in since general dentists carry out most dental care this makes them unsuitable materials for placing
our armamentarium for paediatric dentistry. for children and the long-term prognosis of these a crown using the Hall Technique (without prior
We do a disservice to the patients we care for if crowns in the primary dentition is superior to tooth preparation). Attempts have also been
we do not offer them all the treatment options multi-surface restorations.17,32,33 made to produce crowns with white facings
that are available. overlying the stainless steel substructure but these
For practitioners who treat children, and do Are there aesthetic (white) crowns that have generally been found to fail, with the facings
not use the Hall Technique, the question to be the Hall Technique can be used with? fracturing off for reasons similar to the ceramics
answered is ‘Why not?’ While unfamiliarity with Although the appearance of the tooth due and composite materials.
the Hall Technique is one logical reason, the overall to stainless steel crowns has been found to Unfortunately, it seems unlikely that there will
lack of experience and comfort level with placing be acceptable to children,24 some parents do be a white crown, with the properties required
preformed metal crowns regardless of technique express concern over the aesthetics,23,24 and to allow it to be placed using the Hall Technique,
may be another. In 2015, Casamassimo and Seale the availability of an aesthetic, tooth-coloured in the near future. However, it is generally the
reported that the average number of stainless steel crown would be likely to increase acceptance parents who do not like the appearance and
crowns performed by graduating dental students and use of the technique. rarely the child who is being treated.

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 GENERAL

Why should a clinician choose to ionomer cement, composite resin, or amalgam, attended to, with either pulp therapy through
place a Hall crown? suggesting it becomes one of the treatment the occlusal surface of the crown, or extraction
Children who have limited ability to cope with methods of choice in the primary dentition to of the tooth.
restorative dental treatment are one of the main be carried out
referrals to a paediatric specialist. A convention- What do we see for the Hall
ally placed preformed crown can work almost With the effectiveness, and ease of Technique over the next 10 years?
perfectly, but it requires local anaesthesia, air placement, of Hall crowns proven, are It seems that, at the moment, there is little need
rotor instruments to prepare the tooth and they the answer to providing high- for further randomised control trials of the
often, if a preparation is quite aggressive, a quality management of caries, in any Hall Technique compared with a single other
pulpal exposure, or close proximity to the environment? treatment option. This might seem strange to
dental pulp necessitates a pulpotomy. In many The Hall Technique is one of a range of biolog- say as the question is often raised about the
pre‑cooperative children or those with dis- ically-based options for managing dental caries comparison between conventional- and Hall
abilities, this is only possible under sedation or that the clinician now has at their disposal. Technique-placed crowns. Whilst it might have
general anaesthesia, which has major impacts on Traditionally, preformed stainless steel crowns been helpful to have had that data whilst the
the child, higher risks than chair-side treatment were used to restore primary molar teeth with effectiveness of the Hall Technique was being
and also much higher costs. Thus, a technique multi-surface carious lesions or where pulp proven, it now seems difficult to justify such a
which combines the advantages and high therapy had been carried out. One systematic study as the success rates for both techniques
success rates of a crown without the drawbacks review33 showed a superior clinical performance are so high. Given that there is evidence that
of the conventional, more invasive placement for preformed crowns versus amalgam for the children prefer less invasive treatment, it is ques-
technique can reduce referrals to a specialist and restoration of carious lesions in primary teeth, tionable what outcome of clinical relevance a
many sedation or general anaesthetic events. In with the failure rates being about three times study between Hall crowns and conventional
addition, the arrest of the carious lesion under lower for the crowns than for the amalgam crowns would give. Conventional crown
the crown is in line with all other non-invasive restorations. As described above (Q5), The placement with local anaesthesia and tooth
caries treatments such as lesion inactivation Hall Technique has also demonstrated high preparation (or at least reduction of some
through brushing, fluoride and silver diamine success rates compared to conventional restora- tooth substance) still has a place in the dental
fluoride application. tions, suggesting that they become a treatment treatment of children, for example, when the
In conclusion, with adding the Hall method of choice, for proximal lesions in tooth needs to be modified to achieve a good
Technique to their armamentarium, general carious primary molars. crown fit, or a pulp therapy has been carried out
and family dentists as well as paediatric dentists Based on the accumulated evidence, and the and it is desirable to avoid any occlusal trauma.
gain a highly successful and well-received relative success rates for managing occluso- Also, when multiple crowns are being fitted in
treatment option. Importantly though, in teeth proximal lesions, compared with other well- general anaesthesia cases, the use of conven-
with a plausible risk of irreversible pulpitis or recognised minimally invasive techniques tionally fitted crowns, should be considered,
periradicular periodontitis the Hall Technique such as the atraumatic restorative technique,36 or at least occlusal reduction carried out to
should not be employed as an ‘easy’ way out, as it might be thought that the Hall Technique avoid multiple crowns increasing the vertical
failures will discredit the treating dentist and would be an obvious choice for use in envi- dimension. So, the type of restoration prescribed
his/her choice of indication. ronments with a lack of facilities and infra- should always be based on the clinical situation.
structure, as it does not require an extensive Firstly, is a crown or a restorative filling material
What is the impact of the Hall dental armamentarium and is easy to use. indicated? If a crown is indicated, is there a need
Technique? However, great caution should be exercised in to carry out any tooth preparation? Has there
Despite marked declines in caries in the past these situations before recommending the Hall been pain/infection necessitating a pulp therapy,
30 years, dental caries in pre-school children Technique. As with all the biologically-based or can the Hall Technique be used?
continues be a major health concern for popu- caries management options, excellence in Research is still needed around issues
lations worldwide and is a serious public health diagnosis, treatment-planning and follow-up of costs to provide different treatments in
problem in disadvantaged communities.34 In are imperatives for success, arguably more various settings and relative costs saved as a
this context, the Hall Technique emerges as a so than with conventional treatment. Even result. However, now that the effectiveness
change in the management of dental decay in having correctly diagnosed and appropriately of the Hall Technique and its acceptability to
children, since the technique is simple and less treatment-planned (and this should usually children has been shown, the most significant
invasive, as it does not require local analgesia, involve radiographic examination), Hall factor will be increasing appropriate use of the
carious tissue removal or tooth preparation. crowns are not a ‘place and forget’ technique. technique in practice. To increase the number
It has a reduced treatment time (compared to Teeth should show no symptoms of pulpal of practitioners who use the Hall Technique,
conventional crowns and to plastic restorations) pathology, such as irreversible pulpitis when efforts should be directed in two directions:
and has been reported as more acceptable for a Hall Crown is being considered. If, due to 1) increased opportunities for practitioners to
children. The scientific evidence shows the high a failure in diagnosis, a Hall crown is inad- hear about and learn about the indications for,
success rates as compared to conventional resto- vertently placed on a tooth with irreversible and how to carry out, the Hall Technique. This
rations, making it the most cost-effective restor- pulpal disease, or the lesion reaches the pulp could be through additional published research
ative material35 because it requires less frequent and irreversible pulpal disease results, then this findings, increased course offerings at regional
repair or replacement than multi-surface glass needs to be picked up promptly on review, and and national meetings, and undoubtedly

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 GENERAL

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