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A Dental Technique that is Saving Teeth And Money In Sudan That Could Be Used Worldwide

I think of dentists as being composed and calm. They’ve got all the power over quaking patients, after all. But dentists might be just as nervous as their patients, laughs Fadil Elamin. To quiet his nerves, “Some days I have to take a paracetamol.”

One way to quell the anxiety of both patients and dentists is to reduce the length and invasiveness of a procedure. If that procedure also becomes cheaper and easier to carry out amidst challenging circumstances like power outages, even better.

This win-win-win situation might seem like a pipe dream. Yet Elamin and his colleagues recently published a paper showing that a low-tech method of capping children’s cavities is just as good as the conventional method. It isn’t the first to do so, as several European studies based on randomized controlled trials have also shown the effectiveness of the Hall technique, named after Scottish dentist Norna Hall.

Dental clinic with a patient and staff in white or blue coats
A patient and staff at Khartoum Dentist

In 1997, an audit of Scottish dentists showed that none of them was regularly using preformed dental crowns with children – except for one person. It turned out that Hall had been quietly innovating her own system for capping decaying primary molars: essentially cementing the crowns over them rather than bothering with drilling out the decay, which would have required local anesthesia. Hall was starving the bacteria of oxygen rather than getting rid of them first. Some corners of the media responded with horror at the idea.

Nicola Innes, a pediatric dentist at Scotland’s University of Dundee, reports that her dental hospital has been using Hall’s system for almost 20 years now. She and colleagues are now running a trial of the Hall technique in Tiete, Brazil, where preliminary results indicate a 93% success rate. According to Innes, “the general public do not find it hard to understand why sealing off bugs in decaying tooth tissue stops the decay from progressing when you explain that they can’t grow if they don’t have access to the things they need: sugar, moisture, oxygen, etc. But dentists have been taught that decay is bad and that it must be cut out completely – like gangrene!”

Nicola Hall and a colleague demonstrate the Hall technique, in a video from the Dundee Dental School:

Elamin’s and colleagues’ research in Sudan, published in June in the journal PLOS One, is said to be the first randomized controlled trial of the Hall technique to take place in a low-income country, where the need for simpler, non-invasive techniques is especially high. Based on a two-year study of 164 children aged 5–8, it shows that the Hall technique performs just as well as the conventional method. Tooth survival and gum health, among other indicators, remain the same.

Yet the Hall technique costs Elamin’s clinic just $2.45 and takes only eight minutes to perform, compared to $7.81 and up to 45 minutes for the slower, less comfortable method. The Hall hack also leaves children less anxious about having the procedure done – to the point, according to Elamin, that the kids show off their dental crowns to their siblings and encourage them to get their own. (From braces to grills, it’s astonishing how certain dental hardware can become trendy.)

There are additional advantages. Electricity is unreliable in Sudan, making it important to use methods that don’t rely on constant energy. Khartoum Dentist, Elamin’s clinic, has improvised solutions. They share a generator with other clinics, coordinating when one business needs it and another doesn’t. They have solar panels for lights, and can also use cell phones if needed. The genial Elamin, who also trains rescue horses, chuckles when I ask him whether Khartoum Dentist can only stay open three–four days per week, since they can only rely on electricity then. He points out how sociable it is for patients and dental care providers to chat while waiting for the lights to come back on. “It’s quite pleasant in a way. Socially we’ve adapted to it.”

In general, social support is one compensation for the difficulties of being a practicing dentist in Sudan. Elamin says that it’s common for medical staff to help cover costs for patients, for whom a $4 dental procedure, for instance, would be a big burden. “Sudan isn’t for the faint-hearted,” Elamin acknowledges; since the middle of the 20th century, the city has faced several civil wars and revolutions, with the latest one ending earlier this year. This was personal for the staff of Khartoum Dentist. Elamin says that two employees were arrested from the clinic, and a part-time employee was killed in a riot elsewhere in the city.

A video including footage shot from the roof of Khartoum Dentist shows the scale of the protests:

Amazingly, Elamin and his coauthors were working on the paper during the protests. It was an urgent matter for them, as an insurance company had stated that there wasn’t enough of an evidence base to cover Hall procedures. So the researchers set out to extend this evidence – with the result that the Hall technique is now included in Sudan’s national insurance, according to Elamin.

Another challenge is a global one: worsening nutrition. Elamin recounts, “I go to places in Sudan where there’s no electricity, no running water, but they have a billboard advertising fizzy drinks. The diet has changed from a good diet to a bad diet. And dentistry hasn’t caught up.” There’s not enough preventive care, so tooth extractions are common. According to Elamin, “nearly every 12-year-old knows what it is to have a tooth taken out in Sudan. And that’s what a bad diet does in a population such as ours.”

There’s also the brain drain to contend with. Elamin says, “I get asked that all the time: ‘Why are you here? Why did you leave England? Are you crazy?’” It’s common for Sudan’s highly skilled medical professionals to leave for countries with higher pay and living standards, particularly Gulf countries and Ireland. This is one reason Elamin prefers to hire women in his clinic, as they’re much less likely to migrate than men. And it’s another reason no-drill dentistry procedures are so useful: while clinical skills are of course important, Elamin asserts that a dental therapist with two years of training can perform the Hall technique.

Innes agrees that the procedure is “very simple to carry out but you have to have good diagnostic skills…and confidence as it takes quite a bit of a push (or for the child to bite) to put them on.” She currently runs one-day courses training dentists and therapists in the Hall technique.

Patients and staff in a brightly lit dental clinic
Khartoum Dentist

Elamin cautions that this isn’t a one-size-fits-all solution. It works with juvenile teeth because “children’s teeth adapt more readily than adults’ do,” but wouldn’t be appropriate on teeth that are infected or abscessed.

To be fair, questions still remain about other potential dental problems that haven’t been tested for with the Hall technique. The counterargument is that a decaying tooth isn’t wholly healed; rather, the most obvious problems are avoided. And of course it’s hard to determine the lifetime effects of a practice that’s only been documented for two decades.

The Hall technique has suffered from the stigma of being considered “sloppy dentistry.” Innes recounts, “It’s been called ‘battlefield dentistry’ as it seems too ‘low-tech’ to be high quality. I’ve been accused (and still am regularly) of being a poor-quality children’s dentist and told that I wouldn’t ‘get away’ with that kind of treatment in XXX place.”

Innes argues that this is partly due to an outdated perception that an easy procedure can’t be successful. Elamin, meanwhile, believes that it should be used more widely around the world, including in affluent countries.

Spending less time and money at the dentist’s office, while getting the same result? That’s compelling.

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