Indeed there are good findings when the SSCs are used properly. It becomes an alternative treatment in Pediatric Dentistry, however it must be placed together with motivational techniques and oral health promotion not only for the children, but to the parents and caregivers. The Hall technique has an evidence-base showing that it is acceptable to children. Crowns placed using the Hall Technique have good long term outcomes (pain/infection and need for replacement) compared with standard fillings. So we can choose, for each case, which oral reabilitation program we will offer to our children. Here in Brazil, most of the parents are very worried about the esthetics on deciduous teeth and we use another techniques too. The Minimal Intervention concept is growing very fast, and we always try to maintain the tooth, even avoiding pulpal therapy when we remove possibily the minimal of the carie´s lesion or even don´t remove it at all. These approach will have success if there is a clinical and radiographic sistematic evaluation; not only of the local carie´s lesion but also the children and family habits that may influence positively or negatively, depending on the presence of bacteria, frequency of carbohidrate diet, saliva and all the other factors, including social-demographic, that helps the carie´s disease development.

From my personal expirience,I confirm that we can achieve better long term results with SSC's, further I personally use exclusively copper ZOP cement to place the SSC's, for adults as well, which delivers a greater antibiofilm protection and so far (6 years) I never had to deal with secondary decay, even on patient with poor hygiene

.

Thank you Mauricio and Nicola. I´m also using SSCs with success. Actually we are doing some research on the success rates of SSCs and we did not found in the literature any hint whether there is a relationship between the clinical success of the SSCs and the extent of the carious lesion (proxmal vs. non-proximal lesions) or the pulp treatment. Somehow it seems, that it doesn`t matter, what we do - the SSCs (with good seal) are successfull - even when we are not removing any caries.

Is that your experience or observation too?

To be true, I always do partial decay excavation generally without anesthesia, kind of ART, in order to collect more diagnostic vitality signs and verify the decay patterns.

therefore not strictly to be considered the same as the Hall technique... But very similar and I guess providing similar results.

Generally GIC is the standard of care to lute SSC's.... It is quite accepted that GIZ placed on active decay defects may give poor results.... I wonder why there is not more interest for ZOP uses..?

I do try to use high-viscosity ionomers when possible with a good success rate... and an easier cooperation with children

Question to E.Casals...? ...high-viscosity ionomers for luting SSC's or to restore decay defects ?

YES, recently we published a systematic review and meta analysis regarding primary molar pulpotomy in "clinical oral investigation" and the obtained results revealed that: "Compared to amalgam restoration, success rate was significantly greater with SS crown".

for further detail please read the following article: Mineral trioxide aggregate versus formocresol pulpotomy: a systematic review and meta-analysis of randomized clinical trials.

Hello Prof. Asgary,... how are you ?

If you allow me to add a comment to your message, I would say that regarding primary molar pulpotomy, it is quite accepted that SSC's offer better mechanical protection >>better results Vs.Amalgam.

I guess the above question concern the HALL technique, in order to avoid or reduce need for pulpotomy and how far decay progression can be stopped or controlled with SSC's (partial vs.NO decay excavation) and effective prevent endodontic problems.

Hello, I see that this is an important issue to discuss. I am happy to learn how is your experience. Maybe this following article can help with some positive data of the Hall technique.

Sealing caries in primary molars: randomized control trial, 5-year results.

Innes NP, Evans DJ, Stirrups DR.

J Dent Res. 2011 Dec;90(12):1405-10. doi: 10.1177/0022034511422064. Epub 2011 Sep 15.

PMID:21921249[PubMed - indexed for MEDLINE]

Well, there is another question about the use of GIC instead of ZOP made by Dr Nicola Minotti. Sorry if I didn´t understand it right: when you say ZOP you mean zinc phosphate? That´s how I understood, but please correct me if I am wrong. The GIC have some advantages like the chemical adhesion and biocompatibility, so these could make us choose it because its benefits must be higher than when we use ZOP. But I understand that we have very nice results using ZOP and I don't see any problems using it. However, I only would be worried in deep cavities because of the low pH at the first time. But with the adequate pulp protection and clinical following, I think it wouldn't be a problem.

Thanks Mauricio for your message , let us have a closer look to some points:

- GIC advantages >chemical adhesion >> YES But usually tested effective on healthy dentin = full excavated decay

->> and biocompatibility,...maybe... but. I guess not more than ZOP = inorganic

further GIC takes up water and over time can deteriorate under bacterial colonization

-ZOP- pH >> everyone seem to be scared about it !!

I agree as you mention, that it should not be placed close to the pulp after complete decay excavation...BUT for partial decay excavation , ART procedures or The Hall technique, there is absolute no reason to be worried about the pH .anyway , if preferred , a protective coat of varnish .can be easily placed.

I'm more concerned about biofilm control around the SSC's poor margin fitting, which is occurring in some cases and the cement excess related gingival health outcome,...

Best regards

Hi there,

I have only just picked up on this interesting thread and have very much enjoyed reading what everyone thinks. I would like to add my own thoughts on this as I have spent quite a bit of time looking at it.

Stainless steel crowns have been used for over 50 years in paediatric dentistry but it is still quite a hot topic – non-paediatric dentists hardly use them (throughout the world – not just in the UK), some parents (and societies) don’t like the aesthetics, the Hall Technique seals in caries which some people are still uncomfortable with. So how much high quality evidence is there for them? Well, we carried out a Cochrane review of the evidence directly for stainless steel crowns compared with using rigorous Cochrane methodology and found no high quality randomized trials to include http://summaries.cochrane.org/CD005512/preformed-metal-crowns-for-managing-decayed-primary-molar-teeth-in-children so I was delighted to read Prof Asgary’s review. Many thanks for this nice piece of work. The observational studies consistently support crowns being more successful than fillings but are highly biased.

We are currently updating the Cochrane review and this may, this time, give some more answers to the fascinating original question that Ina asked! Is there any data on clinical success of stainless steel crowns in primary molars influenced by the extension of the carious lesion? Also, we are currently looking at this question using Hall Technique crowns (because of course, with Hall crowns, we seal ALL of the caries in under the crowns) and their success and failures then looking back at radiographic and clinical characteristics. I don’t know exactly what we will find because we are only just starting this project but in our treatment planning, we use a radiological “marker” to decide whether a crown is likely to be successful or not: if we can see what appears to be a “normal” band of dentine radiographically on a bitewing, then we say that a Hall crown is likely to be successful. This seems to work (and is what we recommend in our downloadable manual that is free to anyone - Innes NPT and Evans DJP (2009) The Hall Technique A child-centred approach to managing the carious primary molar - A Users Manual (at bottom of Publications page) but we’ll know better after our study.

The problem we have is that so many researchers use different ways of measuring how much caries is there and in the other relevant Cochrane review Techniques for managing decay in teeth, we found that it was variable http://summaries.cochrane.org/CD003808/techniques-for-managing-decay-in-teeth but we did consistently find, like other similar reviews that sealing in caries is not detrimental in primary teeth.

So, does the extent of caries influence the success of the crown? Probably! But we don’t know how much is too much! We do know that the original thought that marginal ridge breakdown indicates the need for a pulpotomy based on histological signs (work by Duggal and Noor) doesn't translate from the lab to the clinical setting and that the presence of inflammation in the pulp doesn’t mean the pulp is terminally ill necessarily but it does mean that it needs some help to alter the biofilm (by sealing in, removing some, constant removal through cleaning etc).

Sorry, I seem to have written a lot but I was very excited to see such an interesting topic! I look forward to hearing what you all think (if you have managed to read to this far without falling asleep!).

Kind regards to you all,

Nicola

Hello,

Thak you Dr Nicola Minotti! I fully understand your point of view. I think that our goal is the same: find the best treatment to the children, and if we have reached it we are successful.

Dr Nicola Innes I definetely did not fall asleep during the reading of your text, I found it very useful and I am very happy that you joined to this topic.

Best regards to you all,

Mauricio

Thank you all for sharing your interesting thoughts and expereineces with SSCs. Dr. Nicola Innes - I completely agree with you, also regarding the Dilemma: How much caries is too much for minimal Intervention. In our study, there was no significant difference in clinical succesfull SSCs comparinng single surface lesions with multiple surface lesions. But we did not investigate how profund carious lesions were. As I see, other Researchers are on this Topic and I´m so courious about the results.

Best regards,

Ina

HI Ina, thank you for sharing the findings of your study. I have a couple of questions for you. Was it the Hall Technique (sealing in caries with no tooth removal) or was it conventional crowns (with caries removal and tooth preparation) that you did? Also, did you have pre-treatment radiographs?

Hi Nicola, we did conventional crowns - with caries removal an a lot of pulpotomies. And - unforntunately we do not have pre-treatment X Rays for all patients. Actually we wanted to do a quality assessment of SSCs after up to 5 years. So we were looking retrospectively after SSCs fitted in a pediatric dental practice.

The Hall Technique; a randomized controlled clinical trial of a novel method of managing carious primary molars in general dental practice: acceptability of the technique and outcomes at 23 months

Nicola P Innes*, Dafydd JP Evans and David R Stirrups