Alternative Caries Management Options for Primary Molars: 2.5-Year Outcomes of a Randomised Clinical Trial

Abstract

Less invasive caries management techniques for treating cavitated carious primary teeth, which involve the concept of caries control by managing the activity of the biofilm, are becoming common. This study aimed to compare the clinical efficacy (minor/major failures) and survival rates (successful cases without any failures) of 3 carious lesion treatment approaches, the Hall Technique (HT), non-restorative caries treatment (NRCT), and conventional restorations (CR), for the management of occlusoproximal caries lesions (ICDAS 3-5) in primary molars. Results at 2.5 years are presented. A total of 169 children (3- to 8-year-olds) were enrolled in this secondary care-based, 3-arm parallel-group, randomised controlled trial. Participants were allocated to: HT (n = 52; sealing caries with stainless-steel crowns without caries removal), NRCT (n = 52; opening up the cavity and applying fluoride varnish), CR (n = 65; control arm, complete caries removal and compomer restoration). Statistical analyses were: non-parametric Kruskal-Wallis analysis of variance, Mann-Whitney U test and Kaplan-Meier survival analyses. One hundred and forty-two participants (84%; HT = 40/52; NRCT = 44/52; CR = 58/65) had follow-up data of 1-33 months (mean = 26). Overall, 25 (HT = 2, NRCT = 9, CR = 14) of 142 participants (17.6%) presented with at least 1 minor failure (reversible pulpitis, caries progression, or secondary caries; p = 0.013, CI = 0.012-0.018; Mann-Whitney U test). Ten (HT = 1, NRCT = 4, CR = 5) of 142 participants (7.04%) experienced at least 1 major failure (irreversible pulpitis, abscess, unrestorable tooth; p = 0.043, CI = 0.034-0.045). Independent comparisons between 2 samples found that NRCT-CR had no statistically significant difference in failures (p > 0.05), but for CR-HT (p = 0.037, CI = 0.030-0.040) and for NRCT-HT (p = 0.011, CI = 0.010-0.016; Kruskal-Wallis test) significant differences were observed. Cumulative survival rates were HT = 92.5%, NRCT = 70.5%, and CR = 67.2% (p = 0.012). NRCT and CR outcomes were comparable. HT performed better than NRCT and CR for all outcomes. This study was funded by the Paediatric Dentistry Department, Greifswald University, Germany (Trial registration No. NCT01797458).

Use of stainless steel crowns to restore primary molars in Germany: Questionnaire‐based cross‐sectional analysis

“…About 1 month after the treatment, there, however, was a complete overbite re‐establishment ( P = 0.317). Similarly, different clinical trials, which used the HT, reported that after crown cementation the occlusal vertical dimension equilibrates after a few weeks with no evidence of adverse effects . Although there is not until now a conclusive explanation for the equilibration of the occlusion, these studies showed the capacity of the primary dentition to adjust to a slightly opened bite caused by the HT.…”

“…More than one decade ago, a different way of fitting SSCs using the Hall Technique (HT) was introduced, in which no part of the carious lesion is removed; instead, the lesion is sealed under a SSC using glass ionomer cement, and no tooth preparation is performed . This is accomplished by arresting the caries activity under the crown, while preserving tooth tissue and pulp vitality . This less invasive method has proved that carious lesions in primary molars can be successfully treated with this technique in the long run.…”

“…For primary teeth, a restoration should ideally function until the tooth sheds naturally. Different studies, however, have shown failure rates of around 20%‐30% for primary molar restorations . Most common reasons for retreatment are as follows: the presence of a new lesion in an unrestored part of the tooth, carious lesions associated with restorations, bulk fracture, and loss of retention.…”

“…Most common reasons for retreatment are as follows: the presence of a new lesion in an unrestored part of the tooth, carious lesions associated with restorations, bulk fracture, and loss of retention. On the other hand, SSCs are extremely long‐lasting restorations, which offer the benefit of complete coronal coverage minimizing the most common reasons for tooth retreatment, with significant lower failure rates in comparison with other restorative techniques for primary molars . Particularly, the HT combines the advantages of this type of restoration with the lower risks for endodontic treatment by sealing the carious lesion instead of excavating it and therefore reducing the risk of pulp damage.…”

“…In general, SSCs have shown consistently high success rates, independently of the technique used (conventional or HT) or type of study (retrospective or prospective/observational or randomized control) . In addition, the effectiveness of the HT has been proved in different settings (primary or secondary care), by clinicians with diverse clinical expertise (undergraduate, dental therapist, general practitioner, or specialist) and in different countries (Australia, Brazil, Chile, Germany, India, Netherlands, New Zealand, UK, the United States, etc.)…”