Cost-effectiveness of the Hall Technique in a Randomized Trial

New dental graduates transition into UK professional practice; a longitudinal study of changes in perceptions and behaviours through the lens of evidence-based dentistry

BACKGROUND

This longitudinal study using qualitative methodology aims to investigate the perceptions, and implementation, of evidence-based guidelines into practice among new dental graduates (NDGs) during their transition from university into professional practice, by identifying factors that influence the adoption of evidence-based practice (EBP) in dental practice.

METHODS

The study invited NDGs from one UK dental school (N = 66) and employed longitudinal, multiple qualitative methodologies for data collection, throughout the participants' Vocational Dental Training (VDT) year. Initial interviews (Interview 1) conducted upon graduation and follow-up interviews (Interview 2) carried out between six and nine months into professional practice were combined with participants longitudinal audio diaries (LADs) recorded between the interviews.

THE STUDY

RESULTS

A total of 12 NDGs agreed to participate. For Interview 1, twelve participants were interviewed, seven of whom agreed to participate in Interview 2 and six recorded the LADs. Interview 1 exposed diverse views among NDGs about EBP, acknowledging its significance but facing obstacles in implementation due to time and financial constraints. They intended to use evidence selectively, often aligning with trainers' or NHS treatment options, while hesitating to fully embrace EBP in a busy dental practice. During VDT, LAD entries showed initial enthusiasm for EBP, but integrating evidence-based guidelines within the NHS system led to pragmatic treatment decisions, balancing gold-standard and cost-effective options. Over time, NDGs became more comfortable with alternative treatments, considering patients' financial constraints, yet they expressed frustration with external pressures limiting their clinical decision-making autonomy. In Interview 2, after six to nine months in practice, NDGs exhibited mixed attitudes towards EBP. Some actively used dental guidelines like SDCEP, others associated EBP with hi-tech or expensive materials, while others would thought to rely on colleagues' recommendations. None consistently sought direct evidence for treatment decisions.

CONCLUSION

NDGs' attitudes towards EBP changed and became more negative over their first year in professional practice, leading to challenges in their applying it. It questions the assumption that teaching EBP during undergraduate education ensures its implementation. Further understanding the influences on the development of attitudinal challenges will help to devise effective strategies for fostering lifelong learning and supporting evidence-based practice in dentistry.

Cost-Effectiveness of Treatment Decisions for Early Childhood Caries in Infants and Toddlers: A Systematic Review

Background and Objectives: Early childhood caries (ECC) is a multifactorial, biofilm-mediated, sugar-related, dynamic disease of primary dental hard tissues occurring in varying degrees of severity in infants and toddlers. Untreated ECC may lead to pain, infections, and severe systemic complications. The aim of this study was to systematically review and evaluate the scientific evidence on the cost-effectiveness of treatment decisions in ECC in infants and toddlers. Materials and Methods: Observational epidemiological studies, i.e., cohort studies, case-control studies, and randomized controlled trials, reporting cost-effectiveness of treatment decisions in ECC in infants and toddlers were included in the systematic review following the PRISMA guidelines. Using an ad hoc search with search terms or keywords (MeSH), electronic databases Embase, MEDLINE via PubMed, Scopus, and gray literature were searched. Results: The search identified 494 articles, of which 446 remained after removing duplicates. A total of 417 articles were excluded after title and abstract evaluation; 29 full-text articles were screened for eligibility, and five articles were discarded. Twenty-four full-text articles were included in the systematic review, assigning 17 to prevention and seven to restoration. Results were heterogeneous; comparability of included studies is difficult because of the different methodologies used. Conflicting efficacies were demonstrated for different interventions implemented, and cost-effectiveness data were documented. Conclusions: Socioeconomic, cultural, and ethnic differences must be considered when comparing conditions in terms of cost-effectiveness. A paradigm shift from surgical towards preventive treatment decisions can be observed. Cost-effectiveness studies on therapies for ECC in infants and toddlers are needed to identify the best practice approach and the most cost-effective therapy decisions.

Survival rate of the Hall technique compared with resin composite restoration in multi-surface cavities in primary teeth: a 1-year randomized clinical trial

BACKGROUND

Hall technique (HT) has been indicated for teeth with dentinal caries lesion; however, extensive cavities, with more than two surfaces still seem challenging for restorative treatment in pediatric dentistry, resulting in a higher failure rate and an increased need for retreatment.

OBJECTIVES

To compare the survival rate of the Hall technique preformed metal crown (HT) with resin composite restoration (RC) for multi-surface cavitated caries lesions in primary molars.

METHODOLOGY

In this multicenter two-arm randomized clinical trial, children between 4 and 9 years of age with at least one primary molar with cavitated caries lesion involving more than two surfaces, including one buccal or palatal/lingual surface, were selected from 17 Brazilian cities. A total of 364 teeth were allocated into two groups: (1) teeth treated with selective caries removal and RC and (2) treated with the HT. The survival rate was assessed at 6 and 12 months after the interventions. Survival analysis was performed with the Kaplan‒Meier method. Cox regression was used to determine the influence of explanatory variables on the survival rate (α=5%).

RESULTS

After 12 months, 292 teeth were re-evaluated. A total of 358 teeth were re-evaluated at least once during the study and included in the survival analysis. The HT (87.8%) resulted in a higher survival rate than RC restoration (75.7%) (p=0.004).

CONCLUSION

HT has a higher survival rate than RC as a treatment for multi-surface cavitated caries lesions in primary teeth. ClinicalTrials.gov: NCT02782390.

Alveolar ridge preservation: Complications and cost-effectiveness

Alveolar ridge preservation is routinely indicated in clinical practice with the purpose of attenuating postextraction ridge atrophy. Over the past two decades numerous clinical studies and reviews on this topic have populated the literature. In recent years the focus has primarily been on analyzing efficacy outcomes pertaining to postextraction dimensional changes, whereas other relevant facets of alveolar ridge preservation therapy have remained unexplored. With this premise, we carried out a comprehensive evidence-based assessment of the complications associated with different modalities of alveolar ridge preservation and modeled the cost-effectiveness of different therapeutic modalities as a function of changes in ridge width and height. We conclude that, among allogeneic and xenogeneic bone graft materials, increased expenditure does not translate into increased effectiveness of alveolar ridge preservation therapy. On the other hand, a significant association between expenditure on a barrier membrane and reduced horizontal and vertical ridge resorption was observed, though only to a certain degree, beyond which the return on investment was significantly diminished.

Survival Analysis and Cost Effectiveness of Silver Modified Atraumatic Restorative Treatment (SMART) and ART Occlusal Restorations in Primary Molars: a randomized controlled trial

OBJECTIVE

To evaluate and compare the clinical performance and cost effectiveness of Silver Modified Atraumatic Restorative Treatment (SMART) and Atraumatic Restorative Treatment (ART) restorations in primary molars over 12 months follow up period.

MATERIALS AND METHODS

Sixty-seven children, aged 5-9 years old having at least one asymptomatic primary molar with active caries, were randomly assigned to either the test arm (SMART) or the control arm (ART). Clinical performance was assessed after 6 and 12-months using the modified United States Public Health Services criteria. The trial was registered at Clinical Trial.gov with a registration number (NCT03881020). Treatment time for each restoration was recorded, Kaplan-Meier survival analysis and the log-rank test were performed (p<0.05) and cost effectiveness was measured at the end of the study.

RESULTS

Both techniques showed comparable clinical performance and the mean survival time was 11.8 and 11.6 months for SMART and ART restorations respectively with no detected significant differences (p=0.416). Mean treatment time for SMART restorations (7.8 min.), however, was significantly lower than ART (15 min.) (p < 0.001). SMART technique, also, showed statistically significant lower mean total cost per restoration (p <0.001).

CONCLUSIONS

Though SMART and ART have comparable clinical performance and survival in single-surface occlusal restorations in primary molars, SMART is less time consuming and more cost effective.

CLINICAL SIGNIFICANCE

Using SMART technique could change paradigms in caries management. Being a patient friendly and cost-effective approach, it could be adopted as a superior treatment option when dealing with young children, those with behavioral and medical challenges and for promoting access to oral care among the underprivileged.

Hall technique for primary teeth: A systematic review and meta-analysis

Background

There has been a debate about the use of Hall Technique (HT), whether it can be considered as a standard technique for the management of carious primary molars.

Aim

To summarise the evidence on HT for managing dentine caries in primary teeth.

Design

MEDLINE, Embase, CENTRAL and Epistemonikos databases were searched for clinical studies conducted from 2007 to 2021 evaluating HT in primary teeth. Two reviewers independently screened, data extracted and quality assessed the studies.

Results

Eleven publications from eight unique studies were included. Four were of low risk of bias overall and five studies were included in a meta-analysis. Overall, HT was 49 % (RR 1.49 [95 % CI: 1.15–1.93], I² =89.5 %, p < 0.001) more likely to succeed. When compared to direct restorations, HT was 80 % more likely to succeed; while similar success was found when compared to conventional preformed metal crowns. HT was also over 6 times (RR 0.16 [95 %CI: 0.10–0.27], I² =0 %, p < 0.001) less likely to fail. Most of the studies included proximal or multi-surface lesions.

Conclusions

HT is successful option for the management of caries in primary teeth, particularly for proximal or multi-surface dentine lesions. It is well-tolerated by children and acceptable to parent, with mild adverse effects reported.

Teaching Minimally Invasive Interventions in Paediatric Dentistry: A Cross-Sectional Survey of Dental Schools in Iran

BACKGROUND

Dental caries is a significant public health problem in Iran. Teaching  minimally invasive interventions in paediatric dentistry may facilitate the provision of treatment for untreated dental caries in children. We evaluated the teaching of such interventions in both undergraduate dental curriculum and Paediatric Dentistry Specialty Training Programme (PDSTP) in Iran.

METHODS

This was a cross-sectional questionnaire-based survey. Participants in this study were the directors of 40 undergraduate programmes and 15 PDSTPs in all Iranian dental schools (response rate = 100%). Descriptive statistics were reported.

RESULTS

The most commonly taught methods were preventive fissure sealant and preventive resin restoration (PRR), which were taught 'both didactically and clinically' in all undergraduate dental programmes. The least commonly taught methods were silver diamine fluoride (SDF), the Hall technique and resin infiltration, which were taught 'both didactically and clinically' in less than 5% of dental schools. The same three methods were the least commonly approaches taught in PDSTP, further, they were less often perceived to be 'essential'.

CONCLUSIONS

There was a notable variation in the teaching of the management of dental caries in Iran's dental education. Some minimally invasive approaches including SDF, the Hall technique and resin infiltration are not being commonly taught in Iranian dental schools despite the evidence base for these techniques.

Interventions for treating cavitated or dentine carious lesions

BACKGROUND

Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

OBJECTIVES

To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps.

SEARCH METHODS

An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions.

MAIN RESULTS

We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

AUTHORS' CONCLUSIONS

Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

Long-term treatment costs and cost-effectiveness of restoration repair versus replacement

OBJECTIVES

When managing partially defective restorations, dentists can choose between repair and replacement. We aimed to assess the long-term treatment costs of repairs and replacements.

METHODS

Partially defective anterior and posterior composite restorations in permanent teeth had been repaired or replaced in a German university hospital and were retrospectively followed until censoring or one of the following events: (1) Extraction, (2) Major complications including placement of indirect restorations, endodontic treatments and extractions, or (3) Any complications including major complications and further direct restorations. Costs were estimated from a German mixed public-private-payer perspective. Cost-effectiveness differences were described using median-based incremental-cost-effectiveness ratios (ICER_MEDIAN). Statistical analysis was performed using generalized linear mixed modeling (GLM), Chi²-test, and Wilcoxon rank-sum test (p < 0.05).

RESULTS

A total of 616 repairs in 468 patients (follow-up: 4.9 ± 4.1 years) and 264 replacements in 218 patients (follow-up: 4.8 ± 4.3) were included. While replacements were associated with higher initial treatment costs, median annualized treatment costs did not significantly differ between repair (47.58 Euro [IQR: 24.41-107.04]) and replacement (50.64 Euro [IQR: 26.30-118.78]; p > 0.05), but were higher for molars (75.53 Euro [IQR: 24.41-92.18]) than incisors (45.03 Euro [IQR: 28.19-168.50]; p = 0.011). The difference in the % of extractions, major and any complications were minimal between both groups. The mean ICER_MEDIAN of replacement vs. repair was -146.8 Euro/% when extractions were considered as outcomes. Regarding major and any complications, mean ICER_MEDIAN amounted to 67.6 Euro/% and 23.9 Euro/%, respectively.

SIGNIFICANCE

Repairs and replacements of partially defective restorations showed similar long-term costs and cost-effectiveness.

Non-invasive treatment approach for hypomineralised second primary molars using preformed metal crowns: results after 1-year follow-up

PURPOSE

To evaluate the clinical and radiological outcome of Hypomineralised Second Primary Molars (HSPM) treated with Preformed Metal Crowns (PMC) using the Hall Technique (HT).

METHODS

This prospective cohort study included healthy children presenting at the pediatric dental clinic of the University Hospitals Leuven (Belgium) with at least one primary molar affected by HSPM. The clinical and radiological situation at baseline and after a follow-up of 1 year was registered in detail using standardized criteria. After plaque removal and gentle drying, PMCs (3 M™ ESPE™ Stainless Steel Crowns) were fitted without administration of local anaesthesia nor tooth preparation. Strict outcome criteria, including gingival health condition, were applied. Informed consent was obtained for all individual participants. The study was approved by the institutional Ethics Committee.

RESULTS

A total of 39 PMCs with a follow-up of 12 months, placed in 15 patients (7 boys and 8 girls), were included. The mean age of the patients at the time of fitting the PMC was 4.6 ± 1.1 years (range: 3-7). None of the PMCs was lost nor failed. Clinical outcome was considered fully successful in 64.1%, radiological outcome in 93.3% of the cases; all other cases were rated as acceptable. The main reason for not being categorized as fully successful was deterioration of the gingival condition. Overall, the treatment was well tolerated and accepted by the patients.

CONCLUSION

PMCs fitted using the HT represent an acceptable and well-tolerated treatment option for the management of HSPM. Gingival condition should be incorporated in outcome assessment.

Economic evaluations in paediatric dentistry clinical trials

Economic evaluations play an important role in identifying the cost-effectiveness of alternative healthcare programmes, informing decisions surrounding funding and the allocation of resources. This paper outlines the basic principles of economic evaluation and how it can be conducted alongside a clinical trial. Furthermore, it considers the ways in which evidence from these studies can be used, and the challenges researchers are faced with when conducting economic evaluations in the field of children's oral health.

Can minimal intervention dentistry help in tackling the global burden of untreated dental caries?

The latest estimates from the Global Burden of Disease study show that dental caries remains a neglected global health issue, with over two billion people suffering the consequences of this highly preventable disease globally. The two main goals of a national health system are to improve population health and reduce health inequalities, which are often achieved through prevention and promotion for everyone, as well as treatment and rehabilitation for the sick. Oral health promotion should be integrated with national policies for the prevention of non-communicable diseases, especially those targeting the intake of free sugars. The ongoing debate on universal health coverage (UHC) offers a unique opportunity to align dental care with essential health services, which all countries are expected to provide. Minimal intervention dentistry (MID) protocols for management of carious lesions, such as the atraumatic restorative technique, silver diamine fluoride and the Hall Technique, could help tackle the global burden of untreated caries as they are cost-effective in the long run. However, the successful implementation in primary dental care and training the new cadre of dentists adequately are pending issues if MID is to facilitate the inclusion of dental care as part of the UHC agenda.

Long-term costs of post-restorations: 7-year practice-based results from Germany

Objectives

We evaluated the initial and follow-up treatment costs of different post-restorations in a practice-based German healthcare setting.

Methods

A total of 139 incisors, canines, or premolars received post-restorations placed by eight general dental practitioners in Germany, and were followed over a mean ± SD 7.1 ± 4.5 years. Preformed metal (MP, n = 68), glass-fiber (GF, n = 28), or cast post-and-core buildups (MC, n = 23) had been used to retain crowns or bridge anchors. Preformed metal and glass-fiber had also been used to retain directly built up post-retained composite restorations (PC, n = 20). Material and treatment costs for the initial post-restorations as well as restorative, endodontic, or surgical re-treatments were estimated from a public-payer-perspective in Germany. Associations between total and annualized total costs and covariates were assessed using generalized linear modeling. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00012938).

Results

MC showed highest initial treatment costs (557.23 Euro), but the least re-treatments (6/23, 26%), while PC showed lowest initial costs (203.52 Euro) but the most re-treatments (11/20, 55%). Costs for MP/GF post-crowns were initially similarly costly (496.47/496.87 Euro), and both also showed similar re-treatments (35%/36%). The overall annual failure rate was 5.2% (MC: 3.5%, MP: 4.6%, GF: 5.3%, PC: 10.3%). Including costs for the resulting re-treatments, mean total costs were 591.66 Euro (MC), 548.31 Euro (MP), 526.37 Euro (GF), and 361.81 Euro (PC). Annualized total costs were 171.36 Euro (MC), 141.75 Euro (MP), 146.12 Euro (GF), and 135.65 Euro (PC). Total and annualized total costs were highest for MC, with PC being the significantly less costly option (p < 0.001).

Conclusions

Within German healthcare, both initial and follow-up costs for post-restorations were considerable. Saving costs initially may, at least partially, be offset by more complications long-term.

Clinical relevance

Dentists need to be aware that the placement of posts is not only initially costly but also comes with significant long-term costs for treating occurring complications. This should be communicated with patients and considered during treatment planning.

Electronic supplementary material

The online version of this article (10.1007/s00784-020-03529-5) contains supplementary material, which is available to authorized users.

Cost-effectiveness of child caries management: a randomised controlled trial (FiCTION trial)

BACKGROUND

A three-arm parallel group, randomised controlled trial set in general dental practices in England, Scotland, and Wales was undertaken to evaluate three strategies to manage dental caries in primary teeth. Children, with at least one primary molar with caries into dentine, were randomised to receive Conventional with best practice prevention (C + P), Biological with best practice prevention (B + P), or best practice Prevention Alone (PA).

METHODS

Data on costs were collected via case report forms completed by clinical staff at every visit. The co-primary outcomes were incidence of, and number of episodes of, dental pain and/or infection avoided. The three strategies were ranked in order of mean cost and a more costly strategy was compared with a less costly strategy in terms of incremental cost-effectiveness. Costs and outcomes were discounted at 3.5%.

RESULTS

A total of 1144 children were randomised with data on 1058 children (C + P n = 352, B + P n = 352, PA n = 354) used in the analysis. On average, it costs £230 to manage dental caries in primary teeth over a period of up to 36 months. Managing children in PA was, on average, £19 (97.5% CI: -£18 to £55) less costly than managing those in B + P. In terms of effectiveness, on average, there were fewer incidences of, (- 0.06; 97.5% CI: - 0.14 to 0.02) and fewer episodes of dental pain and/or infection (- 0.14; 97.5% CI: - 0.29 to 0.71) in B + P compared to PA. C + P was unlikely to be considered cost-effective, as it was more costly and less effective than B + P.

CONCLUSIONS

The mean cost of a child avoiding any dental pain and/or infection (incidence) was £330 and the mean cost per episode of dental pain and/or infection avoided was £130. At these thresholds B + P has the highest probability of being considered cost-effective. Over the willingness to pay thresholds considered, the probability of B + P being considered cost-effective never exceeded 75%.

TRIAL REGISTRATION

The trial was prospectively registered with the ISRCTN (reference number ISRCTN77044005) on the 26th January 2009 and East of Scotland Research Ethics Committee provided ethical approved (REC reference: 12/ES/0047).

Hall Technique for Carious Primary Molars: A Review of the Literature

The high frequency of caries in primary teeth and its inadequate treatment are major public health problems during childhood. Nowadays, the Hall technique is one of the methods used for biological sealing in carious lesions in primary molars. Thus, the bacteria will be sealed from oral environment and the caries will be inactive. The objective of this article was to provide an updated search on the Hall technique description, indication, contraindication, advantages, concerns, success and failure, cost-effectiveness, acceptability, and preference in pediatric dentistry, and to compare the Hall technique with traditional crown preparation and conventional treatment options for carious primary molars. A discussion of the recently published articles on the Hall technique reveals that the Hall technique is considered a promising restorative option with high acceptability and longevity; with low failure rate for managing carious primary molars compared to conventional treatment modalities used in primary care settings. Furthermore, the survival rate of stainless steel crowns (SSCs) is considered high, whether provided using Hall technique or traditional preparation by a pediatric dentist. Thus, the Hall technique can be an effective addition to the clinician’s range of treatment options for carious primary molars. However, it should be chosen in restricted cases.

Less Is More? The Long-Term Health and Cost Consequences Resulting from Minimal Invasive Caries Management

Caries is a chronic disease, with long-term sequelae, often initiated early in life. Managing caries and carious lesions often has long-term consequences. These consequences involve the health (or its absence) generated by a caries management strategy, but also costs. This article discusses the long-term health and costs consequences resulting from different caries management strategies. It is demonstrated why, and under which circumstances, minimal invasive caries management may be beneficial for patients, but also for health services, with regard to both health gained and costs generated. Moreover, possible factors influencing the cost-effectiveness of different caries management strategies will be discussed.

A randomized clinical trial comparing Hall vs conventional technique in placing preformed metal crowns from Sudan

Despite the high success rates of preformed metal crowns (PMCs) in children no randomized clinical trials compare methods of placement and none describe its use in Africa. Our aim was to compare survival and cost-effectiveness of PMCs placed by conventional techniques (CT) and biological Hall techniques (HT) using a prospective randomized control trial in a general dental practice from Khartoum. One hundred and nine and 103 PMCs were placed in randomly selected children (5-8years) with 1–2 carious primary molars using HT and CT respectively and followed for 2 years. Socioeconomic status, periodontal health, occlusion, anxiety, and procedure time were compared using student t-test. Kaplan–Meier survival rates and incremental cost effectiveness ratio (ICER) were compared between CT and HT. CT and HT groups were similar for age, gender, socio-economic status. Survival rates were high (over 90%) for both study arms and not statistically different (p>0.05). Anxiety scores were significantly higher in CT arm after 12 months compared to HT (p<0.001). Clinically, gingival and plaque indices were similar between groups (p>0.05) but occlusions were raised in nearly all subjects in the HT arm (p<0.05). Periodontal health improved, and occlusions adjusted over time in both arms. There were 3 (2.7%) and 6 (5.8%) minor failures, 7 (6.4%) and 6 (5.8%) major failures in HT and CT arms respectively. Mean procedure time was lower in HT (9.1 min) than CT (33.9 min); p<0.001. Mean PMC cost was US$2.45 and US$7.81 for HT and CT respectively. The ICER was US$136.56 more for each PMC placed by CT per life year. We show that PMCs have high survival outcomes in disadvantaged populations similar to results from developed countries. As HT can be carried out by less experienced dental operators and therapists, this biological approach provides a promising cost-effective option to manage caries in developing countries with limited resources.

Trial registration: The trial is registered at clinicaltrials.gov. ClinicalTrial.gov Trial Registration: NCT03640013