Atraumatic restorative treatment compared to the Hall Technique for occluso-proximal carious lesions in primary molars; 36-month follow-up of a randomised control trial in a school setting

Abstract

Background: Atraumatic Restorative Treatment (ART) and the Hall Technique (HT) are both minimally invasive, non-aerosol generating procedures (non-AGPs). They seem to have never been directly compared, nor has the HT been studied in a non-clinical setting. This study compared the HT and ART restorations placed in a school setting after 36 months.

Methods: Children (5-10 yo) who had a primary molar with a dentinal occluso-proximal, cavitated carious lesion were allocated to the ART (selective removal) or HT arms.

Primary outcome: restoration survival over 36-months (using Kaplan-Meier survival analysis, log rank test, and Cox regression).

Secondary outcomes: (1) occlusal vertical dimension (OVD) (1, 2, 3, 4 weeks) and (2) child self-reported discomfort; (3) treatment acceptability (immediately following interventions); (4) Child Oral Health Related Quality of Life (OHRQoL), before treatment and after 6 months and (5) a post hoc analysis of time to tooth exfoliation (1, 6, 12, 18, 24, 30, 36 months).

Results: One-hundred and thirty-one children (ART = 65; HT = 66) were included (mean age = 8.1 ± 1.2). At 36 months, 112 (85.5%) children were followed-up.

Primary outcome: restoration survival rates ART = 32.7% (SE = 0.08; 95% CI 0.17-0.47); HT = 93.4% (0.05; 0.72-0.99), p < 0.001; Secondary outcomes: (1) OVD returned to pre-treatment state within 4 weeks; (2) treatment discomfort was higher for the HT (p = 0.018); (3) over 70% of children and parents showed a high acceptability for treatments, with crown aesthetics being a concern for around 23% of parents; (4) Child OHRQoL improved after 6 months; and (5) teeth treated with the HT exfoliated earlier than those in the ART group (p = 0.007).

Conclusions: Both ART and the HT were acceptable to child participants and their parents and all parents thought both restorations protected their child's tooth. However, the crown appearance concerned almost a quarter of parents in the HT arm. Children experienced less discomfort in the ART group. Although both treatments can be performed in a non-clinical setting and have the advantage of being non-aerosol generating procedures (non-AGPs), the HT had almost three times higher survival rates (93.4%) for restoring primary molar occluso-proximal cavities compared to ART (32.7%).

Trial registration: This trial was registered in ClinicalTrials.gov (NCT02569047), 5th October 2015. https://clinicaltrials.gov/ct2/show/study/NCT02569047?cond=Hall+Technique+Atraumatic+Rest orative+Treatment&draw=2&rank=2.

Keywords: Atraumatic Restorative Treatment; Dental caries; Hall Technique; Management; Non-AGPs; Primary molars; Randomized controlled trial; Restoration.

Fig. 1

Method for measuring the OVD of children in the HT group [32] adapted from van der Zee and van Amerongen [34]

Fig. 2

Wong-Baker Faces Pain Scale [35] used to measure children’s self-reported discomfort level during the intervention

Fig. 3

CONSORT flow diagram of participants' progress through trial phases

Fig. 4

Kaplan–Meier Survival curves over 36 months with follow-up data collected every 6 months for ART and HT (n = 131)

Fig. 5

OVD measurements from one to four weeks for the HT group

Fig. 6

a WBFPS scores’ distribution between the groups (0 = no discomfort to 5 = maximum score for discomfort) at baseline. b WBFPS scores’ distribution between groups (0 = no discomfort to 5 = maximum score for discomfort) after treatment

Fig. 7

Distribution of children’s responses to the 5 questions investigating treatment acceptability for ART and HT. Based on Bell et al. 2010 [28] (n = 131)

Fig. 8

Distribution of parents’ responses to the 5 questions investigating treatment acceptability for ART and HT (ART n = 45/65; HT n = 47/66)

Fig. 9

Kaplan–Meier survival curves related to tooth exfoliation for both groups (n = 125, as six teeth (4.6%) with a Major failure were not included in the analysis)