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Manuscript Title: Comparative Clinical Evaluation of Stainless Steel Crown Restoration Using Conventional, Hall, and Modified Hall Techniques for Managing Carious Primary Molars: An In Vivo Study

Study Design: Three-arm parallel-group randomized clinical trial

Overall Recommendation: Major Revisions Required

Summary

This manuscript reports a three-arm RCT comparing conventional, Hall, and Modified Hall techniques for stainless steel crown (SSC) placement in primary molars in ninety children aged 4-10 years, followed for six months. The topic is clinically relevant and the study design is appropriate. However, there are significant methodological, reporting, statistical, and language issues that must be addressed before the manuscript is suitable for publication.

1. MAJOR CONCERNS

1.1 Methodological / Rationality Issues

a) Superiority Framework with Null Results - Logical Contradiction The authors declare a "superiority framework" in the Methods section yet report no statistically significant differences on any outcome at any time point and conclude all three techniques are "equally effective." A superiority trial requires demonstrating that one intervention is meaningfully better than a comparator. If the study was designed to show superiority but all results are equivalent, the authors must either (i) reframe the design as a non-inferiority or equivalence trial with pre-specified margins, or (ii) explicitly acknowledge this as a negative superiority trial and discuss what that implies. The current framing is contradictory and misleading.

b) Missing Non-Inferiority / Equivalence Margins Related to the above: if the intent is to show that minimally invasive techniques are "not worse" than conventional SSC (which is the clinically meaningful question), pre-specified non-inferiority margins for retention rate and gingival outcomes must be stated in the protocol and Methods. None are provided. Without these, readers cannot judge whether the observed equivalence is clinically meaningful or merely due to insufficient statistical power.

c) Underpowered Sample for Secondary Outcomes Sample size was calculated solely for crown retention (primary outcome). No power calculations are provided for gingival index, plaque index, or parental satisfaction. Given that these secondary outcomes show small numerical differences (e.g., plaque-free scores: 76.7%-90%), it is plausible that the study was underpowered to detect true differences. The authors should acknowledge this limitation explicitly and provide post-hoc power estimates for the secondary outcomes.

d) Follow-up Duration Too Short - Not Adequately Justified A six-month follow-up is acknowledged as a limitation, but the authors do not justify this choice in the Methods. Primary molars may remain in the mouth for several more years. Six months is insufficient to assess clinically meaningful retention failure, carious lesion progression beneath the crown (particularly relevant for Hall Technique where caries is left in situ), or long-term periodontal impact. Many comparable RCTs in this field report 12-36 month follow-up (e.g., Innes et al., ref 3: 23 months; Ayedun et al., ref 9: 12 months). The six-month endpoint weakens the study's contribution to existing literature and must be more explicitly justified.

e) Primary Outcome Definition Incomplete Crown retention is defined using FDI criteria (Alpha = retained and functional; Charlie = complete loss). However, a "Beta" score, representing a retention that is present but suboptimal (e.g., minor marginal discrepancy), is not mentioned. It is unclear whether any intermediate outcomes were recorded or if all crowns were categorized as either Alpha or Charlie only. The absence of intermediate scoring must be explained.

f) Frankl's Scale Scoring Error in Exclusion Criteria The exclusion criteria state: "Children exhibiting negative or definitely negative behaviour (Frankl's rating scale 3 and 4)." This is factually incorrect. On Frankl's Behavioral Rating Scale: Score 1 = Definitely Negative, Score 2 = Negative, Score 3 = Positive, Score 4 = Definitely Positive. The authors appear to have the numbering reversed. The inclusion criteria correctly state "positive or definitely positive behaviour," but the exclusion criteria assign the wrong numerical codes. This must be corrected - the excluded scores should be 1 and 2, not 3 and 4.

g) Wong-Baker FACES Scale Misapplied for Parental Satisfaction The Wong-Baker FACES Pain Rating Scale (ref 7) is a validated tool designed to assess pain intensity in patients - primarily children. Using it to measure "parental satisfaction" is conceptually invalid. The scale measures self-reported pain, not satisfaction or comfort perception in a proxy (parent). The authors should replace this tool with a validated parental satisfaction questionnaire, or clearly justify and reframe what is being measured at baseline (e.g., "parent-reported perception of child's discomfort during treatment"). The title of Table 4 also reads "Parental Satisfaction by Wong Baker Pain Scale," which further conflates pain measurement with satisfaction.

h) Asymmetric Table Denominators Not Explained In Tables 2, 3, and 5, the 6-month total for Group I is 29 (not 30), correctly reflecting one dropout. However, the text says "All randomized participants were analyzed" which contradicts the fact that one participant in Group I was lost to follow-up at 6 months. The authors must clarify: was a per-protocol or intention-to-treat analysis used? If per-protocol, the claim of complete analysis in the abstract is incorrect. A CONSORT flow diagram is absent (see below).

i) No CONSORT Flow Diagram For a randomized clinical trial, a CONSORT participant flow diagram is mandatory in most journals. Its complete absence is a significant reporting deficiency.

j) Baseline Comparability Not Reported No table or text confirms that the three groups were comparable at baseline for relevant variables (age, sex, molar position, caries severity, Frankl score distribution). Without baseline equivalence data, any outcome differences (or lack thereof) cannot be attributed purely to the intervention.

1.2 Reporting and Structural Issues

k) Abstract - Incomplete Reporting

The "Settings and Design" field labels this a "randomized clinical control trial" - the word "control" is unusual here; the standard term is "randomized controlled trial" (RCT).
The abstract does not report confidence intervals or effect sizes for any outcome.
The abstract states "The Hall Technique demonstrated the highest parental satisfaction (86.7%)" but this figure (86.7%) does not match data in Table 5, which shows that "satisfied + very satisfied" responses in the HT group at 6 months total 86.6% (70.0% + 16.7%). This near-match suggests rounding inconsistency; the abstract should precisely match the reported data.

l) Intervention Descriptions Lack Detail

Group I (Conventional): The type, brand, and shade of stainless steel crown is not specified. The cement mixing ratio or brand of glass ionomer is not stated.
Group III (Modified Hall Technique): The description ("minimal tooth modification was performed where required") is vague. What exactly constitutes "minimal modification"? How much proximal reduction, by what instrument, to what depth? This is insufficiently reproducible. The reader must infer everything from the cited references (refs 4 and 5), which is inadequate for a Methods section.

m) Missing Information on Radiographic Assessment The inclusion criteria specify "at least two-thirds root structure radiographically," implying radiographs were taken. The results section makes no mention of radiographic follow-up data. Were bitewing or periapical radiographs taken at follow-up to assess caries progression beneath Hall crowns? This is particularly important given that caries is left unsealed in the HT - radiographic monitoring of lesion progression or arrest is a standard and expected outcome measure.

n) No Adverse Event Table The authors state "No major adverse events were reported" and list one crown loss, but there is no structured adverse events table. Given the Hall Technique leaves caries in situ, clinicians would expect reporting on: tooth vitality, pulpal symptoms, premature exfoliation, and occlusal changes due to the increased vertical dimension introduced by the crown. None of these are formally reported.

2. MINOR CONCERNS

2.1 Statistical Issues

o) P-values Reported Inconsistently

Table 1, 3-month P-value is listed as "____" (blank/dashes). A value or notation (e.g., "N/A" with explanation) must be provided, or the dash must be explained in a footnote.
P-values are reported with inconsistent decimal precision (P = 0.77, P = 0.74, P = 0.67, P = 0.53, P = 0.623, P = 0.558). Standardize to two or three decimal places throughout.
The p-value in Table 5 (6-month retention column) reports P = 1.000 in the abstract but this refers to Table 1. Confirm all p-values are internally consistent between text, abstract, and tables.

p) No Confidence Intervals No confidence intervals are reported for any outcome measure. For a clinical trial, confidence intervals around retention rates and satisfaction proportions are expected and should be provided.

q) Fisher's Exact Test vs. Chi-Square The authors state both Chi-square and Fisher's exact test were used "where appropriate," but do not specify which test was applied to which comparison. Given small expected cell counts in several cells (e.g., zero counts for GI scores 2 and 3), Fisher's exact test should be used for most comparisons. This must be clarified in the statistical methods or as table footnotes.

2.2 Grammar, Language, and Writing

r) Introduction is Excessively Condensed The entire Introduction is only two short paragraphs (approximately 200 words). For a journal article, the Introduction should provide: (1) the burden and prevalence of caries in primary dentition, (2) a more thorough review of existing literature on each technique, (3) a clear statement of research gaps, and (4) a specific hypothesis or research question. The current introduction reads more like an abstract background than an introduction.

s) Specific Language and Grammar Issues

Page 2, line 50: "randomised clinical active trial" - the word "active" is non-standard. The standard terminology is "randomised controlled trial with an active comparator" or simply "three-arm parallel randomised controlled trial."
Page 4, line 77: "Frankl's rating scale 3 and 4" - factual error as noted above.
Page 6, lines 111-113: "Crown retention was assessed according to the Federation Dentaire Internationale (FDI) criteria..." - The correct full form is "Fédération Dentaire Internationale." The acute accent on "Fédération" is missing.
Page 7, line 137: "No statistically significant difference was observed among the groups (P > 0.05)" - This repeats a statement already made earlier. Reduce redundancy.
Page 8, line 153: "Parental satisfaction was assessed immediately after treatment using the Wong-Baker FACES Pain Rating Scale" - As noted above, this is a conceptual misuse of the scale.
Page 11, line 247: "while avoiding local anaesthesia and extensive tooth preparation" - This statement applies to HT but not to MHT, which does involve some tooth modification. The sentence overgeneralizes.
References list: Reference 6 is listed as "Loe H, Silness J." The correct authorship order is "Silness J, Löe H" for the Plaque Index (1964) and "Löe H, Silness J" for the Gingival Index (1963). These are two separate papers published in different years and should be cited separately. Merging them into one citation is inaccurate. Additionally, the special character in "Løe" should be "Löe" (umlaut, not a slashed O).
Discussion, page 10: "Kaptan and Korkmaz¹²" - Reference 12 lists two authors; the citation format is correct, but the paper is described as a "randomized clinical trial" in the reference list yet is grouped in a non-specific manner in the text. This is minor but should be reviewed.
Tables: Table headings use inconsistent capitalization ("Comparison Of Retention Scores" vs. "Comparison of Gingival Index Score"). Standardize to sentence case or title case uniformly.
Table 1: The Charlie score percentage for Group I at 6 months is listed as "03.4%" - this is an unusual format. It should read "3.4%". More importantly, if 1 out of 29 evaluated patients at 6 months lost the crown, the percentage should be 1/29 = 3.45%, not 1/30 = 3.3%. The denominator shifts between 30 and 29 after the dropout. Clarify whether percentages are calculated from 30 (original enrolled) or 29 (followed up).

t) Conclusions Section The Conclusions largely repeat the Results verbatim. A Conclusions section should interpret the clinical significance of the findings, not re-state numbers. The final sentence ("Overall, the Hall Technique and the Modified Hall Technique proved to be effective, minimally invasive alternatives...") is appropriate but needs more nuance given the superiority framework issue raised above.

3. FORMATTING / STRUCTURAL DEFICIENCIES

Missing Element	Required?
CONSORT Flow Diagram	Yes (mandatory for RCTs)
Baseline characteristics table	Yes
Confidence intervals	Yes
Radiographic follow-up data	Yes (for HT/MHT especially)
Structured adverse events table	Recommended
Ethical approval committee name	Not stated
CONSORT checklist	Yes

4. POSITIVE ASPECTS

The study addresses a relevant clinical question with a well-defined three-arm design and adequate allocation concealment.
Blinding of the outcome assessor is a methodological strength and is clearly described.
CTRI registration is provided and reportedly completed before enrollment.
The use of validated indices (Silness and Löe Gingival Index, Plaque Index) for periodontal outcome assessment is appropriate.
The reference list is relevant and mostly current.
The writing is generally clear and readable, with only minor language issues.

Summary of Required Actions

Reframe the trial design as non-inferiority or equivalence (with pre-specified margins), or explicitly acknowledge it as a negative superiority trial.
Correct the Frankl's scale scoring in the exclusion criteria (scores 1 and 2 are negative, not 3 and 4).
Replace or reframe the use of the Wong-Baker FACES scale for parental satisfaction.
Add a CONSORT flow diagram and a baseline characteristics table.
Clarify the per-protocol vs. intention-to-treat analysis and resolve the discrepancy in the abstract.
Add radiographic follow-up data, especially caries progression beneath Hall crowns.
Provide a more detailed description of the Modified Hall Technique procedures.
Standardize p-value reporting and add confidence intervals.
Separate and correct Reference 6 into two distinct citations (Plaque Index 1964, Gingival Index 1963), and correct the spelling of "Löe."
Correct the "03.4%" formatting and clarify the denominator issue in Table 1.
Expand the Introduction to adequately review the literature and state the research gap.

Lets do it one by one starting from abstract till the end

Great approach. Let's go section by section, starting with the Abstract.

Here is the abstract text as written in the manuscript, followed by a detailed critique:

ABSTRACT - Detailed Review

Original Text (reconstructed from the manuscript)

Context: Stainless steel crowns (SSCs) are the restoration of choice for extensively carious primary molars. The Hall Technique and Modified Hall Technique have been proposed as minimally invasive alternatives to conventional SSC placement.

Objective: To compare the clinical performance of SSCs placed using the Conventional Technique, Hall Technique, and Modified Hall Technique in managing carious primary molars.

Settings and Design: Three-arm parallel-group randomized clinical control trial.

Methods: Ninety children aged four to ten years with carious primary molars meeting the eligibility criteria were selected and randomly allocated into Conventional Technique (n=30), Hall Technique (n=30), or Modified Hall Technique (n=30). Clinical assessments were performed at baseline, three months, and six months. The primary outcome was crown retention. Secondary outcomes included gingival health, plaque accumulation, and parental satisfaction. Outcome assessment was performed by a blinded examiner. Data were analyzed using IBM SPSS Statistics Version 26.0, with P < 0.05 considered significant.

Results: All randomized participants were analyzed. At six months, crown retention rates were 96.7%, 100%, and 100% in the Conventional, Hall, and Modified Hall groups, respectively (P = 1.000). Healthy gingival status was observed in more than 93% of participants, and plaque-free scores ranged from 76.7% to 90.0% across groups. The Hall Technique demonstrated the highest parental satisfaction (86.7%). No significant intergroup differences were observed.

Conclusions: All three techniques demonstrated excellent short-term clinical performance. The Hall and Modified Hall techniques were effective minimally invasive alternatives to the conventional approach.

Trial Registration: CTRI/2025/08/092251 [Registered on: 04/08/2025]

Keywords: Stainless steel crowns, Hall Technique, Modified Hall Technique.

CRITIQUE

Settings and Design

Issue 1 - Wrong terminology: "Randomized clinical control trial" is incorrect. The accepted term is "randomized controlled trial" (RCT). The word order matters - "controlled" is an adjective modifying "trial," not a noun. "Clinical control" is not standard nomenclature in any major journal style.

Correction: Change to "Three-arm parallel-group randomized controlled trial."

Methods

Issue 2 - Vague eligibility description: The phrase "with carious primary molars meeting the eligibility criteria" is circular and uninformative. Readers of an abstract should not need to read the full paper to understand who was enrolled. A brief qualifier (e.g., "with extensively carious primary molars without signs of pulpal involvement") would make the abstract self-contained.

Correction: Replace with a brief clinical descriptor of the key inclusion criterion.

Issue 3 - No mention of study center or setting: "Settings" is a declared abstract field, yet no setting information appears in the Methods sub-section. Where was the study conducted (university clinic, hospital, private practice)? This matters for generalizability.

Correction: Add the study setting (e.g., "Department of Paediatric Dentistry, [Institution], conducted between August 2025 and March 2026").

Issue 4 - No mention of follow-up duration: The Methods paragraph mentions "baseline, three months, and six months" for assessments, but never explicitly states the total follow-up period. A reader scanning the abstract cannot quickly identify that this is a 6-month study.

Correction: Add "over a six-month follow-up period" at the end of the Methods sentence.

Results

Issue 5 - "All randomized participants were analyzed" is inaccurate: This statement appears to be a standard CONSORT-style phrase, but it is factually wrong in this study. One participant in Group I (Conventional) was lost to follow-up at six months. The correct statement would be "Eighty-nine of ninety randomized participants completed the six-month follow-up" or the authors must clarify that intention-to-treat imputation was performed.

Correction: Revise to accurately reflect the 1 dropout, or state the analytical approach used.

Issue 6 - The P-value for retention is reported as P = 1.000: Reporting a p-value of exactly 1.000 is unusual and requires explanation. This likely results from Fisher's exact test when all groups have identical or near-identical outcomes, but it should be noted as such. Presenting P = 1.000 without context can appear like a typographical error to readers.

Correction: Consider writing "(P = 1.00, Fisher's exact test)" with a brief note, or report it as "P > 0.05" for brevity in the abstract.

Issue 7 - "Healthy gingival status was observed in more than 93% of participants" is ambiguous: It is not clear whether this refers to 3-month or 6-month data, or both combined across all groups. The lowest recorded value (93.3%) is for Groups I and III at 6 months, so the statement is technically true but imprecise.

Correction: Specify the time point: "At six months, healthy gingival status (Gingival Index score 0) was maintained in 93.3%-96.7% of participants across groups."

Issue 8 - "Plaque-free scores ranged from 76.7% to 90.0% across groups" collapses time points: This range mixes the 3-month Group III low (76.7%) with the 6-month Group II and III high (90.0%). Reporting a single range across different time points is misleading.

Correction: Separate by time point or report the 6-month values, which are more clinically meaningful: "At six months, plaque-free scores ranged from 83.3% to 90.0%."

Issue 9 - "The Hall Technique demonstrated the highest parental satisfaction (86.7%)" needs context: The figure 86.7% represents "satisfied + very satisfied" responses in the HT group at 6 months (70.0% + 16.7% = 86.7%, though the table shows 16.6%, creating a minor rounding discrepancy). Without stating the scale used, the time point, or what this percentage represents, the statement is incomplete and potentially confusing.

Correction: "At six months, 'satisfied' or 'very satisfied' responses were reported by 80.0%, 86.7%, and 76.7% of parents in the Conventional, Hall, and Modified Hall groups, respectively (P = 0.558)." This gives the reader the full comparative picture rather than highlighting just one group.

Conclusions

Issue 10 - "Excellent short-term clinical performance" is an overclaim: The word "excellent" is subjective and not supported by a pre-defined benchmark in the Methods. The results show high retention and no adverse events, but "excellent" has no operational definition in this study.

Correction: Replace with "high" or "comparable" clinical performance, which is defensible.

Issue 11 - Conclusions do not acknowledge the superiority framework failure: The study was designed as a superiority trial but found no differences. The Conclusions should not read as if the study achieved its stated aim. At minimum, add a qualifier such as: "No statistically significant differences were demonstrated among the three techniques under a superiority framework."

Keywords

Issue 12 - Too few and too narrow keywords: Only three keywords are listed, all of which appear in the title. Keywords should include terms that help indexing and discoverability beyond the title - for example: "primary molars," "paediatric dentistry," "minimally invasive dentistry," "randomized controlled trial," "dental caries."

Correction: Expand keywords to 5-8 terms, including MeSH-compatible terms not already in the title.

Summary Table - Abstract Issues

#	Location	Type	Issue	Action
1	Settings & Design	Terminology	"clinical control trial"	Change to "controlled trial"
2	Methods	Clarity	Vague eligibility phrase	Add brief clinical descriptor
3	Methods	Missing info	No study setting stated	Add institution/clinic type
4	Methods	Missing info	Follow-up duration absent	State "six-month follow-up"
5	Results	Factual error	"All participants analyzed"	Revise - 1 participant dropped out
6	Results	Statistical	P = 1.000 unexplained	Clarify test used or write P > 0.05
7	Results	Ambiguity	GI time point not specified	Specify 6-month data
8	Results	Misleading	Plaque range mixes time points	Separate by time point
9	Results	Incomplete	Satisfaction figure lacks context	Report all three groups' values
10	Conclusions	Overclaim	"Excellent" undefined	Replace with "high"
11	Conclusions	Logical	Superiority framework not addressed	Add qualifying statement
12	Keywords	Indexing	Only 3 narrow keywords	Expand to 5-8 MeSH terms

Ready to move on to the Introduction whenever you are. Just say the word.

The phrase "with carious primary molars meeting the eligibility criteria" is circular and uninformative. Readers of an abstract should not need to read the full paper to understand who was enrolled. A brief qualifier (e.g., "with extensively carious primary molars without signs of pulpal involvement") would make the abstract self-contained. change this into a simple language

Sure. Here it is in plain language:

The problem: The original sentence says children were enrolled "meeting the eligibility criteria" - but that tells the reader nothing. Every study enrolls participants who meet its own criteria. It's like saying "we included patients who qualified to be included." It adds no information.

What the abstract should do instead: Give the reader the one or two most important facts about who was enrolled, right there in the abstract, without making them hunt through the Methods section.

Original sentence:

"Ninety children aged four to ten years with carious primary molars meeting the eligibility criteria were selected..."

Suggested revision:

"Ninety children aged four to ten years with extensively carious primary molars showing no clinical or radiographic signs of pulpal involvement were randomly allocated..."

What changed and why:

"meeting the eligibility criteria" is removed - it was redundant
"extensively carious" tells the reader the severity of disease being treated
"no clinical or radiographic signs of pulpal involvement" is the single most important eligibility boundary in this type of study - it tells the reader these were treatable teeth, not teeth needing pulp therapy or extraction
The sentence now stands on its own without needing the full paper

The "Settings and Design" field labels this a "randomized clinical control trial" - the word "control" is unusual here; the standard term is "randomized controlled trial" (RCT). No mention of study center or setting: "Settings" is a declared abstract field, yet no setting information appears in the Methods sub-section. Methods- The original sentence says children were enrolled "meeting the eligibility criteria" - but that tells the reader nothing. Every study enrolls participants who meet its own criteria. It's like saying "we included patients who qualified to be included." It adds no information. Original sentence:"Ninety children aged four to ten years with carious primary molars meeting the eligibility criteria were selected..." Suggested revision:"Ninety children aged four to ten years with extensively carious primary molars showing no clinical or radiographic signs of pulpal involvement were randomly allocated..." Results "All randomized participants were analyzed" is inaccurate sentence. "Healthy gingival status was observed in more than 93% of participants" is ambiguous: It is not clear whether this refers to 3-month or 6-month data, or both combined across all groups. "Plaque-free scores ranged from 76.7% to 90.0% across groups" collapses time points: This range mixes the 3-month Group III low (76.7%) with the 6-month Group II and III high (90.0%). Reporting a single range across different time points is misleading. In the conclusion it is written - All three techniques demonstrated excellent short-term clinical performance. Kindly explain what do you mean by short -term clinical performance? Trial registration number should be removed from the abstract. These are the final statements I chose to include. just arrange them properly for a reviewer style

Here is the full abstract critique arranged in formal reviewer style, using only the points you have selected:

Reviewer Comments - Abstract

Comment 1 - Settings and Design: Incorrect terminology

The study design is described as a "randomized clinical control trial." This phrasing is incorrect. The accepted and widely recognized term is "randomized controlled trial" (RCT). The word "controlled" is an adjective that modifies "trial," and reversing the word order changes the meaning. The authors are advised to correct this throughout the manuscript wherever the study design is mentioned.

Comment 2 - Settings and Design: Study setting is absent

The abstract includes a dedicated "Settings and Design" field, yet no information about the study setting is provided anywhere in this section. Readers should be able to identify where the study was conducted directly from the abstract. The authors should add a brief statement specifying the type of institution (e.g., university dental clinic, teaching hospital) and the duration of the study.

Comment 3 - Methods: Circular eligibility statement

The sentence currently reads:

"Ninety children aged four to ten years with carious primary molars meeting the eligibility criteria were selected..."

The phrase "meeting the eligibility criteria" is circular and adds no information. Every study by definition enrolls participants who meet its own criteria. An abstract should be self-contained, and readers should not need to refer to the full text to understand who was enrolled. The authors are advised to replace this phrase with a brief clinical descriptor of the key inclusion criteria. The following revision is suggested:

"Ninety children aged four to ten years with extensively carious primary molars showing no clinical or radiographic signs of pulpal involvement were randomly allocated..."

Comment 4 - Results: Inaccurate claim of complete analysis

The Results section states: "All randomized participants were analyzed." This statement is factually incorrect. As reported later in the same manuscript, one participant in the Conventional Technique group experienced crown loss and was unavailable for complete evaluation, resulting in only 29 participants in that group at the six-month follow-up. The authors must revise this sentence to accurately reflect the number of participants who completed the study, and should clarify whether a per-protocol or intention-to-treat analysis was applied.

Comment 5 - Results: Ambiguous gingival health statement

The statement "Healthy gingival status was observed in more than 93% of participants" does not specify the time point to which it refers. It is unclear whether this figure represents the three-month data, the six-month data, or a combined estimate across both follow-up visits and all groups. Given that gingival outcomes were assessed at two separate time points, the authors should report the values for each time point separately and specify the groups to which the percentages apply.

Comment 6 - Results: Misleading plaque score range

The statement "plaque-free scores ranged from 76.7% to 90.0% across groups" is misleading because it collapses data from two different time points into a single range. The lower value of 76.7% corresponds to Group III at three months, while the upper value of 90.0% corresponds to Groups II and III at six months. Presenting these as a single range implies they are directly comparable, which they are not. The authors should report plaque scores separately for each follow-up visit, or at minimum restrict the range statement to a single time point, preferably the six-month endpoint as the primary study conclusion is based on it.

Comment 7 - Conclusions: "Short-term clinical performance" requires definition

The Conclusions state: "All three techniques demonstrated excellent short-term clinical performance." The term "short-term" is used without any definition or qualification. What duration constitutes short-term in the context of primary molar restorations? Six months may be considered short-term relative to the lifespan of a primary molar, which can remain in the mouth for several years, but this is not stated. The authors should either define what they mean by "short-term" (i.e., explicitly state "over a six-month follow-up period") or remove the term and write the conclusion with the actual follow-up duration. Additionally, the word "excellent" is subjective and is not supported by a pre-specified benchmark in the Methods section. A more defensible word such as "high" or "comparable" is recommended.

Comment 8 - Trial Registration: Should be repositioned

The trial registration number is currently placed at the end of the abstract. Trial registration details are not part of the scientific content of the abstract and are more appropriately placed in the Methods section of the main text, or as a footnote on the title page, in accordance with the formatting guidelines of most peer-reviewed journals. The authors should remove it from the abstract and relocate it accordingly.

dont elaborate it so much

Reviewer Comments - Abstract

Comment 1 - Settings and Design: Incorrect terminology

The study is described as a "randomized clinical control trial." The correct term is "randomized controlled trial (RCT)." Please correct this throughout the manuscript.

Comment 2 - Settings and Design: Study setting is absent

The abstract has a dedicated "Settings and Design" field but no setting information is provided. The authors should add the type of institution and the study duration.

Comment 3 - Methods: Circular eligibility statement

"...with carious primary molars meeting the eligibility criteria..." is uninformative. The abstract should be self-contained. Suggested revision:

"Ninety children aged four to ten years with extensively carious primary molars showing no clinical or radiographic signs of pulpal involvement were randomly allocated..."

Comment 4 - Results: Inaccurate claim of complete analysis

"All randomized participants were analyzed" is incorrect. One participant in Group I was lost to follow-up at six months. This must be corrected, and the type of analysis (per-protocol or intention-to-treat) should be stated.

Comment 5 - Results: Ambiguous gingival health statement

"Healthy gingival status was observed in more than 93% of participants" does not specify the time point. Please report values separately for three and six months.

Comment 6 - Results: Misleading plaque score range

"Plaque-free scores ranged from 76.7% to 90.0%" mixes values from different time points. The 76.7% is from three months (Group III) and 90.0% is from six months (Groups II and III). Please report these separately by time point.

Comment 7 - Conclusions: "Short-term" is undefined

"Excellent short-term clinical performance" - "short-term" is not defined anywhere in the manuscript. Replace with the actual follow-up duration: "...over a six-month follow-up period." Also, "excellent" is subjective with no pre-specified benchmark; replace with "high" or "comparable."

Comment 8 - Trial Registration: Reposition

Trial registration details do not belong in the abstract. Relocate to the Methods section or title page footnote per standard journal formatting guidelines.

lets move on to introduction

Here is the Introduction as written in the manuscript:

Original Text

Dental caries in primary molars remains a major childhood concern. Stainless steel crowns (SSCs) are the gold standard for restoring extensively decayed molars, but conventional placement requires local anaesthesia and tooth preparation, often causing anxiety¹. The Hall Technique (HT) offers a minimally invasive alternative, sealing lesions beneath SSCs without preparation, though tight contacts may cause seating discomfort. The Modified Hall Technique (MHT) uses minimal proximal slicing for passive crown placement. As comparative clinical data remain limited, this study aims to evaluate the clinical performance of SSCs placed using conventional, Hall, and modified Hall techniques.

Reviewer Comments - Introduction

Comment 1 - Length and depth: Grossly inadequate

The entire Introduction is a single paragraph of approximately 150 words. This is insufficient for a journal article reporting a randomized controlled trial. A proper Introduction should cover:

The prevalence and burden of dental caries in the primary dentition
The rationale for SSC use and its limitations
A focused review of existing evidence on each of the three techniques being compared
A clear statement of the research gap
The study aim or hypothesis

None of points 1, 3, or 4 are adequately addressed. The authors should substantially expand the Introduction.

Comment 2 - Unsupported opening claim

"Dental caries in primary molars remains a major childhood concern" is stated without a citation. This is an epidemiological claim that requires a reference, ideally from a global or national prevalence study.

Comment 3 - "Gold standard" claim needs a citation

"Stainless steel crowns are the gold standard for restoring extensively decayed molars" - this is a strong claim that must be supported by a reference. Reference 1 (Seale and Randall, 2015) cited at the end of the sentence applies to the anxiety point, not the gold standard claim. Citations should be placed immediately after the specific claim they support.

Comment 4 - Hall Technique description is superficial

The HT is described in one clause: "sealing lesions beneath SSCs without preparation." There is no mention of when it was introduced, by whom, or what the existing evidence base looks like. A technique being tested in an RCT deserves at least a brief evidence summary in the Introduction.

Comment 5 - Modified Hall Technique introduced without context

The MHT is described in a single sentence with no background on who developed it, when, or what prior studies have shown. Given that this is one of the three study arms, it warrants a proper introduction.

Comment 6 - Research gap is asserted without evidence

"As comparative clinical data remain limited" - this is the stated justification for the study, but no evidence is provided to support it. The authors should briefly cite what comparative data do exist and explain specifically what gap this study fills.

Comment 7 - No hypothesis or research question stated

The Introduction ends with the study aim but no hypothesis. For a superiority-designed RCT, the hypothesis (or at minimum the primary research question) should be explicitly stated.

Comment 8 - Inconsistent capitalization

In the Introduction, the techniques are referred to as "conventional, Hall, and modified Hall techniques" (lowercase) whereas throughout the rest of the manuscript they are written as "Conventional Technique, Hall Technique, Modified Hall Technique" (capitalized). Pick one style and apply it consistently throughout.

Summary

The Introduction in its current form reads more like an abstract background section than a full Introduction. It needs to be substantially rewritten and expanded before the manuscript is suitable for publication.

club the comments 2-8 in a single paragraph

Reviewer Comments - Introduction

Comment 1 - Length and depth: Grossly inadequate

The entire Introduction is a single paragraph of approximately 150 words. This is insufficient for a journal article reporting a randomized controlled trial. A proper Introduction should cover:

The prevalence and burden of dental caries in the primary dentition
The rationale for SSC use and its limitations
A focused review of existing evidence on each of the three techniques being compared
A clear statement of the research gap
The study aim or hypothesis

None of points 1, 3, or 4 are adequately addressed. The authors should substantially expand the Introduction.

Comment 2 - Multiple content and consistency issues

Several specific issues require attention within the existing text. The opening claim that "dental caries in primary molars remains a major childhood concern" is stated without a citation, as is the claim that SSCs are the "gold standard" - both require references, and the citation for the gold standard claim should not be shared with the anxiety reference placed at the end of the sentence. The Hall Technique and Modified Hall Technique are each described in a single clause with no mention of their origin, development, or existing evidence base; given that these are two of the three study arms, they deserve a proper evidence summary. The justification for the study - "comparative clinical data remain limited" - is asserted without citing what data do exist or explaining precisely what gap this study fills. No hypothesis is stated, which is expected for a superiority-designed RCT. Finally, the technique names are written in lowercase in the Introduction ("conventional, Hall, and modified Hall techniques") but are capitalized throughout the rest of the manuscript; this inconsistency should be resolved uniformly across the entire manuscript.

lets move to the materials and methods section

Here is the Materials and Methods text from the manuscript:

Original Text

This study was designed as a three-arm, parallel-group, randomised clinical active trial with a superiority framework and an allocation ratio of 1:1:1. The unit of randomisation was the individual participant. The study protocol was finalised before participant enrolment, and no substantive changes were made to the trial design, eligibility criteria, interventions, outcomes, follow-up schedule, or statistical analysis plan after trial commencement.

Patients or members of the public were not involved in the design, conduct, reporting, or dissemination plans of this trial. The study was conducted at a single study centre, with participant recruitment and clinical procedures carried out between August 2025 and March 2026.

The study protocol was reviewed and approved by the Institutional Ethics Committee. Written informed consent was obtained from parents or legal guardians prior to participation, and assent was obtained from children when appropriate.

The trial was registered with the Clinical Trials Registry–India (CTRI) before enrollment of the first participant (CTRI Registration No.: CTRI/2025/08/092251, Registered on 04/08/2025).

Inclusion criteria: Primary molars with large occlusal caries or multi-surface caries without any clinical signs and symptoms of pulpal involvement. Teeth with recurrent restoration failure. Patients exhibiting high caries risk. Presence of at least two-thirds root structure radiographically. Patients having good general health. Children exhibiting positive or definitely positive behaviour (Frankl's rating scale).

Exclusion criteria: Teeth with signs or symptoms of irreversible pulpitis. Carious tooth which is considered non-restorable or indicated for extraction. Teeth with clinical or radiographic signs of pulpal exposure or periradicular pathology. Teeth demonstrating radiographic signs of pathological internal or external resorption. Medically compromised patients. Children exhibiting negative or definitely negative behaviour (Frankl's rating scale 3 and 4).

Participants were recruited consecutively from patients attending the outpatient clinic of the Department of Paediatric and Preventive Dentistry.

The sample size was calculated based on the primary outcome of crown retention. Assuming a significance level (α) of 0.05 and a statistical power of 80%, the required sample size was determined by the statistician using G*Power software (version 3.1)². Based on anticipated differences in clinical success rates reported in previous studies, a minimum of thirty participants per group was required. The final sample comprised ninety participants equally allocated to the three study groups.

Participants were randomly assigned to one of three treatment groups using a computer-generated randomisation (Research Randomizer) sequence prepared by an investigator not involved in clinical procedures or outcome assessment. Allocation concealment was achieved using sequentially numbered, opaque, sealed envelopes opened only after participant enrollment.

Blinding of operators and participants was not feasible. However, outcome assessments were performed by a calibrated examiner who was blinded to group allocation.

Group I - Conventional Technique: Complete caries removal was performed, followed by restoration of the cavity using Type II glass ionomer cement. Tooth preparation included occlusal and proximal reduction to create adequate space for SSC placement. Following crown selection, adaptation, contouring, and crimping, the SSC was cemented using Type I glass ionomer luting cement.

Group II - Hall Technique: No local anaesthesia, caries removal, or tooth preparation was performed. Orthodontic separators were placed when required to obtain proximal space. An appropriately sized SSC was selected, adjusted as necessary, and cemented using Type I glass ionomer luting cement according to the standard Hall Technique principles³.

Group III - Modified Hall Technique: SSC placement was carried out using a modified Hall Technique protocol⁴˙⁵. Minimal tooth modification was performed where required to facilitate crown placement while preserving the principles of biological caries sealing and minimal intervention. The selected crown was then cemented using Type I glass ionomer luting cement.

Postoperative instructions were provided to all participants and their parents. Clinical evaluations were performed at baseline, three months, and six months by a calibrated examiner. Crown retention was assessed according to the Federation Dentaire Internationale (FDI) criteria, where an Alpha score indicated that the restoration was completely retained and functional, whereas a Charlie score indicated complete loss or dislodgement of the restoration. Gingival health was evaluated using the Silness and Løe Gingival Index, and plaque accumulation was assessed using the Silness and Løe Plaque Index⁶. Parental satisfaction was evaluated immediately after treatment using the Wong-Baker FACES Pain Rating Scale⁷ and during the three- and six-month follow-up visits using a five-point Likert scale. All participants were monitored throughout the study period for any adverse events, including crown loss, pain, soft tissue irritation, pulpal symptoms, or any other treatment-related complications.

All data were entered into Microsoft Excel and analysed using IBM SPSS Statistics for Windows, Version 26.0. Descriptive statistics were used to summarise the data. Intergroup comparisons were performed using the Chi-square test and Fisher's exact test where appropriate. Statistical significance was set at P < 0.05.

Reviewer Comments - Materials and Methods

Comment 1 - Study design terminology: "randomised clinical active trial"

The phrase "randomised clinical active trial" is non-standard. The correct terminology is "randomised controlled trial with an active comparator" or simply "three-arm parallel randomised controlled trial." The word "active" does not belong as a standalone descriptor in the design label and may confuse readers.

Comment 2 - Superiority framework: Contradicts the results

The study is declared to follow a superiority framework, which requires demonstrating that one intervention performs significantly better than the comparator. However, no significant differences were found on any outcome. The authors must either:

Reframe the design as a non-inferiority or equivalence trial with pre-specified margins, or
Explicitly acknowledge this as a negative superiority trial in the Discussion and Conclusions.

As currently written, the declared framework and the reported conclusions are contradictory.

Comment 3 - Eligibility criteria: Frankl's scale scores are incorrect

The exclusion criteria state: "Children exhibiting negative or definitely negative behaviour (Frankl's rating scale 3 and 4)." This is factually wrong. On Frankl's Behavioural Rating Scale:

Score 1 = Definitely Negative
Score 2 = Negative
Score 3 = Positive
Score 4 = Definitely Positive

The scores to be excluded should be 1 and 2, not 3 and 4. This error must be corrected, as it directly affects the eligibility criteria of the study.

Comment 4 - Eligibility criteria: Written as fragments, not sentences

Both the inclusion and exclusion criteria are written as a series of disconnected sentence fragments rather than complete sentences. This is grammatically incorrect and reads like a copied checklist. The criteria should either be presented as a properly formatted numbered or bulleted list with complete sentences, or written as continuous prose.

Comment 5 - Ethics committee: Name not stated

The manuscript states "the study protocol was reviewed and approved by the Institutional Ethics Committee" but does not name the committee or provide the approval reference number. Most journals require the full name of the ethics body and the approval number for verification.

Comment 6 - Sample size: Insufficient detail

The sample size calculation states that "based on anticipated differences in clinical success rates reported in previous studies, a minimum of thirty participants per group was required" - but does not state the specific effect size, retention rates, or reference study used as the basis for this calculation. Readers cannot evaluate whether the sample size is appropriate without this information.

Comment 7 - Group III (Modified Hall Technique): Description is too vague

The MHT is described as "minimal tooth modification was performed where required." This is insufficiently detailed for a Methods section. What instrument was used? How much proximal reduction? To what endpoint? A reader should be able to reproduce the procedure from the Methods description alone. Referring the reader to cited references (refs 4 and 5) is not a substitute for a clear procedural description.

Comment 8 - FDI crown retention criteria: Beta score not mentioned

Crown retention is described using only Alpha (fully retained) and Charlie (complete loss) scores. The FDI World Dental Federation criteria include a Beta score representing acceptable but suboptimal performance. The authors should clarify whether Beta scores were recorded and, if not, explain why this intermediate category was excluded from assessment.

Comment 9 - Wong-Baker FACES Scale: Misapplied tool

The Wong-Baker FACES Pain Rating Scale is a validated instrument for assessing self-reported pain intensity in patients, primarily children. Using it to measure parental satisfaction is conceptually inappropriate - parents are not reporting their own pain; they are reporting a perception of their child's comfort or their satisfaction with the procedure. The authors should either replace this with a validated parental satisfaction instrument or clearly reframe what is being measured at baseline (e.g., "parent-perceived procedural discomfort of the child").

Comment 10 - "Silness and Løe": Incorrect special character

The name is spelled "Løe" (with a slashed O) throughout the manuscript. The correct spelling is "Löe" (with an umlaut). Additionally, the Plaque Index (Silness and Löe, 1964) and the Gingival Index (Löe and Silness, 1963) are two separate publications with different author orders. They should be cited as two separate references, not merged into a single reference (ref 6).

Comment 11 - "Fédération Dentaire Internationale": Missing accent

The organization name is written as "Federation Dentaire Internationale" without the accent. The correct spelling is "Fédération Dentaire Internationale." This should be corrected.

Comment 12 - Statistical methods: Test allocation not specified

The authors state that both Chi-square and Fisher's exact test were used "where appropriate" but do not specify which test was applied to which comparison. Given that several cells contain zero counts (e.g., GI scores 2 and 3), Fisher's exact test should have been used for most comparisons. The authors should clarify in the text or as table footnotes which test was applied to each outcome.

Comment 13 - CONSORT flow diagram: Absent

No CONSORT participant flow diagram is provided. This is mandatory for reporting a randomized controlled trial and is required by most peer-reviewed journals. The diagram should show the number of patients screened, eligible, enrolled, randomized, followed up, and analyzed at each time point.

Comment 14 - Baseline comparability: Not reported

There is no table or description confirming that the three groups were comparable at baseline for key variables such as age, sex, molar type, caries severity, and Frankl score distribution. Without this, outcome differences (or their absence) cannot be confidently attributed to the intervention alone.

Alpha beta charlie scoring is for usphs criteria if i am not wrong please check fdi criteria?

Searching the Web

FDI World Dental Federation criteria crown restoration scoring Alpha Beta Charlie

Searching the Web

USPHS criteria Alpha Beta Charlie dental restoration vs FDI criteria

You are correct. Here is the clarification:

You are right - Comment 8 needs to be revised.

Alpha, Bravo, Charlie, Delta scoring belongs to the modified USPHS (Ryge) criteria, not the FDI criteria.

The FDI World Dental Federation criteria (Hickel et al., 2007, revised 2010) use a numerical 1-5 scoring system:

Score 1 = Clinically excellent / very good
Score 2 = Clinically good
Score 3 = Clinically sufficient / satisfactory
Score 4 = Clinically unsatisfactory (repair needed)
Score 5 = Clinically poor (replacement necessary)

Scores 1-3 are acceptable; scores 4-5 are unacceptable.

Revised Comment 8 for the manuscript:

Comment 8 - Crown retention criteria: Wrong scoring system cited

The manuscript states that crown retention was assessed "according to the Federation Dentaire Internationale (FDI) criteria, where an Alpha score indicated complete retention and a Charlie score indicated complete loss." This is incorrect. Alpha and Charlie are scores from the modified USPHS (Ryge) criteria, not the FDI criteria. The FDI criteria use a numerical 1-5 scoring system across aesthetic, functional, and biological categories. The authors must either correct the name of the criteria to "modified USPHS criteria" if that is what was used, or revise the scoring description to match the actual FDI numerical scoring system. This is a factual error that must be corrected before publication.

Patients or members of the public were not involved in the design, conduct, reporting, or 58 dissemination plans of this trial. isnt this wrong english

This is a nuanced point. The sentence is grammatically correct but it is contextually and logically problematic in this manuscript. Here is the breakdown:

Grammatically - the sentence is fine. It is a standard declarative statement in passive construction and is used widely in clinical research reporting, particularly as part of a Patient and Public Involvement (PPI) declaration, which many journals now require authors to include.

However, the issue is contextual and logical:

The subjects of this study are patients - specifically, children and their parents. Saying "patients or members of the public were not involved in the design or conduct" of a study that recruited, treated, and followed up 90 child patients sounds contradictory at first read.

The distinction the authors are trying to make is between:

Study participants (who receive the intervention) - these were involved
Patient representatives or public advisors (who help shape the research design, outcomes, and dissemination) - these were not involved

This is the PPI declaration in its standard form, but the sentence as written does not make that distinction clear. A reader unfamiliar with PPI reporting norms could easily misread it as saying patients were not involved in the trial at all, which is obviously wrong.

Suggested revision:

"No patient representatives or members of the public were involved in the design, conduct, reporting, or dissemination plans of this trial."

This makes it clear that it is advisory/representative involvement that was absent, not patient participation itself.

lets do the results

Here is the Results section as written in the manuscript:

Original Text

A total of ninety children meeting the eligibility criteria were randomised equally into three groups: Conventional Technique (Group I), Hall Technique (Group II), and Modified Hall Technique (Group III) (n = 30 each). All participants received the allocated intervention and were evaluated at baseline and three months. At the six-month follow-up, one participant in Group I experienced crown loss; therefore, twenty-nine participants in Group I and thirty participants each in Groups II and III were available for final evaluation.

Crown retention was assessed at three and six months. At three months, all crowns remained retained, resulting in a 100% retention rate in all groups. At six months, retention rates were 96.7% in Group I and 100% in Groups II and III. No statistically significant difference was observed among the groups (P > 0.05) (Table 1).

Gingival health was evaluated using the Silness and Løe Gingival Index. At three months, a gingival index score of 0 was observed in 96.7% of participants in Groups I and II, and 93.3% in Group III. At six months, healthy gingival conditions were maintained in 93.3%, 96.7%, and 93.3% of participants in Groups I, II, and III, respectively. Mild gingival inflammation (score 1) was observed in a small number of participants, whereas no participant exhibited scores of 2 or 3 at either follow-up interval. No significant intergroup differences were found at three months (P = 0.77) or six months (P = 0.74) (Table 2).

Plaque accumulation was assessed using the Silness and Løe Plaque Index. At three months, plaque-free scores (score 0) were recorded in 83.3%, 86.7%, and 76.7% of participants in Groups I, II, and III, respectively. At six months, the corresponding values were 83.3%, 90.0%, and 90.0%. Mild plaque accumulation (score 1) was observed in a limited number of participants, while a score of 2 was recorded only in isolated cases. No participant demonstrated a score of 3 at either follow-up visit. Intergroup comparisons revealed no statistically significant differences at three months (P = 0.67) or six months (P = 0.53) (Table 3).

Parental satisfaction was assessed immediately after treatment using the Wong-Baker FACES Pain Rating Scale, and at three and six months using a five-point Likert scale. At baseline, most parents reported low treatment-related discomfort across all groups. At three months, satisfaction responses were predominantly neutral to satisfied, with satisfaction or very high satisfaction reported by 40.0%, 53.3%, and 50.0% of parents in Groups I, II, and III, respectively (P = 0.623). At six months, overall satisfaction levels increased, with "satisfied" and "very satisfied" responses reported respectively by 60.0% and 10.0% of parents in Group I, 70.0% and 16.7% in Group II, and 66.7% and 10.0% in Group III. No statistically significant difference was observed among the groups (P = 0.558) (Tables 4 and 5).

No major adverse events, including pain, soft-tissue complications, or pulpal symptoms, were reported during the study period. One minor failure (crown loss) was recorded in Group I at the six-month follow-up.

Reviewer Comments - Results

Comment 1 - Opening sentence: Circular eligibility phrase repeated

The Results section opens with "ninety children meeting the eligibility criteria" - the same circular phrase flagged in the abstract. The Results section should not re-describe eligibility; it should simply state that ninety children were randomised into three equal groups. The eligibility description belongs in the Methods section only.

Suggested revision: "A total of ninety children were randomised equally into three groups..."

Comment 2 - Crown loss participant: Inconsistent handling across the manuscript

The text correctly notes that one participant in Group I experienced crown loss at six months, reducing the evaluable number to 29. However, this same participant is described as having experienced "crown loss" - which is also recorded as the primary outcome failure (Charlie score). It is unclear whether this participant was:

Lost to follow-up, or
Present at follow-up but with a failed crown

These are two different situations. If the participant attended the six-month visit but had a failed crown, they were evaluated and should be counted in the analysis as a failure, not excluded. The sentence "twenty-nine participants were available for final evaluation" implies the participant was absent, but the adverse events paragraph states crown loss was "recorded" - implying they were present. This contradiction must be clarified.

Comment 3 - Table 1: Denominator inconsistency and percentage error

In Table 1, the Charlie score percentage for Group I at six months is listed as "03.4%" - two errors in one figure:

The leading zero ("03.4%") is a formatting error and should read "3.4%"
More importantly, 1 crown loss out of 29 evaluated participants = 3.45%, not 3.3%. The percentage of 3.3% uses a denominator of 30 (the originally enrolled number), not 29 (the actual evaluated number). The authors must decide and consistently apply whether percentages are calculated from the enrolled (n=30) or evaluated (n=29) denominator, and this must be consistent across the text and all tables.

Comment 4 - Gingival Index: "Løe" spelling error

As noted in the Methods comments, "Løe" (slashed O) is incorrect throughout the manuscript. The correct spelling is "Löe" (umlaut). This appears again here and should be corrected in all instances.

Comment 5 - Table 2: Total row denominator inconsistency

In Table 2 (Gingival Index), the Total row at six months shows Group I as 29/96.7%, yet the individual score rows for Group I at six months add up correctly to 29 (27 + 2 = 29). However, the total percentage is listed as 96.7% instead of 100%. The total row should always sum to 100% of the evaluated participants within each group. This appears to be a formatting or calculation error and must be corrected.

Comment 6 - Parental satisfaction: Misapplied outcome tool carried into Results

As flagged in the Methods, the Wong-Baker FACES Pain Rating Scale is a pain assessment tool, not a satisfaction measure. This issue now manifests in the Results where the authors report "most parents reported low treatment-related discomfort" at baseline - note the word "discomfort," not "satisfaction." This confirms that what was actually measured at baseline was discomfort, not satisfaction, yet the outcome is labelled as parental satisfaction throughout. The authors must use consistent and accurate terminology for what was measured at each time point.

Comment 7 - Parental satisfaction: Combining "satisfied" and "very satisfied" without a total

At six months, the satisfied and very satisfied figures are reported separately in the text but their combined totals (the clinically meaningful figure) are not stated. Readers must add them manually (e.g., Group I: 60.0% + 10.0% = 70.0% but the abstract claims 80.0% for Group I). Cross-checking reveals that the abstract figure of 80.0% for Group I matches 60.0% satisfied + 10.0% very satisfied only if the neutral category is excluded from the denominator, or there is a calculation error. The authors must reconcile these figures between the Results text, the tables, and the abstract.

Comment 8 - No confidence intervals reported

Throughout the Results, only point estimates and p-values are reported. No confidence intervals are provided for any outcome measure. For a clinical trial, confidence intervals around the primary outcome (retention rate) and key secondary outcomes are expected and should be added.

Comment 9 - Adverse events: Incomplete reporting

The adverse events paragraph states only that "no major adverse events were reported" and notes one crown loss. For a study involving the Hall Technique, where caries is intentionally left sealed beneath the crown, the following should have been monitored and reported:

Pulp vitality at follow-up visits
Radiographic evidence of caries arrest or progression beneath the crown
Occlusal changes due to increased vertical dimension from the crown
Premature tooth exfoliation

None of these are reported. The adverse events section as written is insufficient for a technique that leaves active caries in situ.

Comment 10 - P-value in Table 1 at three months is blank

Table 1 shows a blank ("____") for the p-value at three months. Since all groups had 100% retention at three months with zero variance, no statistical test could be performed. This must be noted explicitly in the table as a footnote (e.g., "Statistical comparison not performed as all groups achieved 100% retention at three months") rather than left blank.

move to discussion

Here is the Discussion section as written in the manuscript:

Original Text

The present randomised clinical trial compared the clinical performance, periodontal outcomes, and parental satisfaction associated with stainless steel crowns (SSCs) placed using the Conventional Technique (CT), Hall Technique (HT), and Modified Hall Technique (MHT) in primary molars. Overall, all three techniques demonstrated high clinical success over the six-month follow-up period, with no statistically significant differences among the groups.

Retention of SSCs is an important determinant of long-term clinical success because crown loss compromises the marginal seal and may require retreatment. In the present study, all crowns were retained at three months, resulting in a 100% success rate in all groups. At six months, one crown loss was observed in the CT group, reducing retention to 96.7%, whereas both HT and MHT maintained 100% retention, with no statistically significant difference among the groups (P > 0.05). These findings are consistent with previous literature demonstrating excellent retention of SSCs irrespective of placement technique. Mittal et al.⁸ reported a 5% retention failure rate in conventionally placed SSCs over thirty-six months, while Ayedun et al.⁹ observed 8.7% decementation in the CT group over twelve months. Similarly, Ludwig et al.¹⁰ reported an overall success rate of 94% for conventional SSCs, with retention loss being one of the causes of failure.

The favourable retention observed with HT in the present study is comparable to the findings of Innes et al.³, who reported very low minor failure rates with Hall crowns. Ayedun et al.⁹ and Sharaf et al.¹¹ also demonstrated 100% retention for HT crowns during twelve-month follow-up periods. Retention in HT is mainly achieved through preservation of natural cervical undercuts and adhesion provided by glass ionomer cement.

The MHT was developed to overcome seating difficulties associated with tight proximal contacts in the standard HT. In the present study, MHT demonstrated 100% retention, supporting previous observations by Midani et al.⁵, who reported that all crown losses occurred in the standard HT group, whereas no crown loss was seen with MHT. Arepogu et al.⁴ similarly reported zero crown loss in MHT compared with minor failures in HT. Minimal proximal reduction in MHT may facilitate passive crown seating without compromising natural retentive contours, thereby improving crown adaptation and stability.

Maintenance of gingival and periodontal health around SSCs is essential for long-term success. In the present study, gingival health remained favourable in all groups. At six months, Gingival Index score 0 was observed in 93.3% of CT participants, 96.7% of HT participants, and 93.3% of MHT participants, with no significant difference among groups (P = 0.74). Similarly, plaque-free scores at six months were 83.3% in CT and 90% in both HT and MHT groups (P = 0.53). These findings are in agreement with previous studies demonstrating good periodontal compatibility of SSCs when properly adapted. Mittal et al.⁸ reported gingival health around conventional SSCs comparable to healthy control teeth. Kaptan and Korkmaz¹² observed significant reductions in plaque and gingival scores in HT restorations over time, suggesting that the smooth metallic surface of SSCs creates a cleansable environment with reduced plaque retention.

The present results further support the concept that minimally invasive approaches such as HT and MHT do not adversely affect periodontal tissues despite the absence of conventional tooth preparation. The transient gingival blanching sometimes associated with HT does not appear to result in long-term inflammation. In MHT, minimal proximal slicing may permit easier crown seating and reduce pressure on gingival tissues during placement. The favourable plaque and gingival scores observed across all groups may be attributed to the highly polished surface of SSCs, which is less plaque-retentive than cavitated carious lesions. Prabhu et al.¹³ similarly reported reduced plaque accumulation and gingival inflammation around well-adapted SSCs. These findings highlight that periodontal health is influenced more by marginal adaptation and oral hygiene maintenance than by the specific crown placement technique.

Parental acceptance is an important consideration in paediatric dentistry because it influences treatment compliance and future dental behaviour. In the present study, parental satisfaction improved over time in all groups. At three months, satisfaction or very high satisfaction was reported by 40.0% of parents in the CT group, 53.3% in the HT group, and 50.0% in the MHT group. At six months, these values increased to 80.0%, 86.7%, and 76.7%, respectively, with no statistically significant differences among the groups (P > 0.05). Although statistical significance was not observed, minimally invasive approaches showed comparatively greater parental acceptance. Santamaria et al.¹⁴ reported significantly more negative child behaviour with conventional restorative procedures than with HT. Similarly, Innes et al.³ demonstrated that 83% of carers and 77% of children preferred the Hall Technique over conventional restorations. The higher acceptance associated with HT may be attributed to elimination of local anaesthesia, rotary instrumentation, and extensive tooth preparation, thereby reducing anxiety and discomfort during treatment. However, tight proximal contacts in standard HT may occasionally produce transient pressure during crown seating. MHT was introduced to minimise this discomfort through limited proximal reduction. Arepogu et al.⁴ reported significantly lower discomfort scores and greater child preference for MHT compared with standard HT. In the present study, MHT also demonstrated high parental satisfaction, suggesting that easier crown seating and reduced procedural discomfort contribute positively to treatment acceptance. Despite concerns regarding the metallic appearance of SSCs, most parents appeared to prioritise durability, comfort, and absence of pain over aesthetics. Bell et al.¹⁵ similarly reported that the majority of parents had minimal aesthetic concerns regarding SSCs.

The findings of the present study support the clinical effectiveness of both biological and conventional approaches for SSC placement in primary molars. HT and MHT demonstrated retention, periodontal outcomes, and parental acceptance comparable to the conventional approach while avoiding local anaesthesia and extensive tooth preparation. Among the minimally invasive techniques, MHT appears particularly advantageous because it combines the biological benefits of HT with easier crown seating and improved patient comfort.

There were certain limitations to the present study, including the follow-up duration being limited to six months; therefore, long-term restorative outcomes could not be assessed. Furthermore, the study was conducted at a single centre with a relatively small sample size, which may limit the generalisability of the findings. In addition, operator blinding was not feasible owing to the inherent differences in the clinical treatment protocols. Future long-term, multicentre clinical trials with larger sample sizes are recommended to validate these findings.

Reviewer Comments - Discussion

Comment 1 - Opening paragraph repeats the Results

The Discussion opens by restating the study design and summarising the results. This is redundant. A Discussion should begin by contextualising the key finding within the existing literature, not by repeating what was already reported in the Results section. The opening paragraph adds no interpretive value and should be rewritten to lead with the principal finding and its significance.

Comment 2 - Superiority framework never addressed

The study was declared a superiority trial in the Methods, yet the Discussion makes no mention of this. The Discussion should explicitly acknowledge that the superiority hypothesis was not confirmed - no technique was shown to be significantly better than another. Instead, the authors interpret the absence of difference as a positive finding and conclude equivalence, which is not what a superiority trial tests. This is a fundamental logical gap that must be addressed.

Comment 3 - Misleading comparison with longer follow-up studies

The authors compare their six-month retention data with studies that followed patients for twelve months (Ayedun et al.⁹, Sharaf et al.¹¹) and thirty-six months (Mittal et al.⁸). Comparing retention rates across studies with very different follow-up durations is misleading. Retention failures tend to accumulate over time, so a six-month 96.7% retention rate is not directly comparable to a 94% rate over thirty-six months. The authors should explicitly acknowledge this limitation when drawing comparisons and avoid presenting them as equivalent findings.

Comment 4 - Mittal et al. (ref 8) is not an SSC study

Reference 8 (Mittal et al., 2016) is titled "Clinical performance of indirect composite onlays as esthetic alternative to stainless steel crowns." This is a study comparing composite onlays to SSCs, not a study of conventional SSC placement technique. Citing it as evidence for conventional SSC retention failure rates is inappropriate and misleading. The authors should either replace this reference with a more directly relevant study or accurately describe what Mittal et al. actually compared.

Comment 5 - Caries status beneath Hall crowns not discussed

The Hall Technique intentionally leaves caries unsealed. The Discussion does not address what happened to the carious lesions beneath the HT and MHT crowns during the six-month follow-up. Were radiographs taken? Was caries arrest or progression assessed? This is arguably the most clinically important biological question for these techniques and its complete absence from the Discussion is a significant gap. The authors should either report and discuss this, or explicitly acknowledge it as a limitation.

Comment 6 - "Avoiding local anaesthesia and extensive tooth preparation" overgeneralises

In the penultimate paragraph, the authors write that HT and MHT demonstrated comparable outcomes "while avoiding local anaesthesia and extensive tooth preparation." This statement is accurate for HT but not entirely accurate for MHT, which by definition involves minimal proximal reduction - a form of tooth preparation. The statement overgeneralises and should be qualified.

Comment 7 - Parental satisfaction figures in Discussion do not match the Results

The Discussion states that at six months, satisfaction or very high satisfaction values were "80.0%, 86.7%, and 76.7%" for Groups I, II, and III respectively. However, adding the satisfied and very satisfied figures from Table 5: Group I = 60.0% + 10.0% = 70.0%, not 80.0%. The figure of 80.0% does not match the table data. This numerical discrepancy must be investigated and corrected. All figures cited in the Discussion must be verified against the tables.

Comment 8 - Limitations paragraph is superficial

The limitations are listed briefly in a single short paragraph. Several important limitations are missing:

No radiographic follow-up data
No assessment of caries progression beneath Hall crowns
Use of an inappropriate outcome tool for parental satisfaction (Wong-Baker scale)
No intention-to-treat analysis described
The superiority framework not being met

The limitations section should be more thorough and honest about the methodological gaps identified throughout the manuscript.

Comment 9 - "Biological and conventional approaches" terminology

The phrase "biological and conventional approaches" in the penultimate paragraph is informal and undefined. In the context of this manuscript, "biological" refers to caries-sealing techniques (HT and MHT). The authors should use consistent and defined terminology throughout - either "minimally invasive" vs "conventional" as used elsewhere in the manuscript, or define "biological approach" formally before using it.

Comment 10 - Conclusion within Discussion

The final paragraph of the Discussion functions as a conclusion, summarising findings and recommending future research. This content belongs in the Conclusions section, not the Discussion. The Discussion should end with a reflection on the study's contribution to the field and its limitations, not with a summary statement that duplicates the Conclusions.

Move to the Conclusions section for final review

Here is the Conclusions section as written in the manuscript:

Original Text

Stainless steel crowns placed using the Conventional Technique, the Hall Technique, and the Modified Hall Technique demonstrated high clinical success over the six-month follow-up period. Crown retention rates were comparable among the three techniques, with no statistically significant differences observed. Gingival health and plaque accumulation remained within clinically acceptable limits in all groups throughout the study period. High levels of parental satisfaction were reported for all treatment modalities, although the minimally invasive techniques showed a tendency toward greater acceptance. Overall, the Hall Technique and the Modified Hall Technique proved to be effective, minimally invasive alternatives to the conventional surgical approach for the management of carious primary molars.

Reviewer Comments - Conclusions

Comment 1 - Largely a repetition of the Results

The Conclusions section reads almost word for word as a condensed version of the Results section. A Conclusions section should not restate numerical findings - those belong in the Results. Instead, it should convey the clinical meaning and take-home message of the findings. The authors should rewrite this section to answer the question: "What does this mean for clinical practice?"

Comment 2 - Superiority framework contradiction

As flagged throughout this review, the study was designed as a superiority trial. The Conclusions make no acknowledgement of this. Stating that the techniques are "comparable" or that minimally invasive techniques are "effective alternatives" is a conclusion consistent with an equivalence or non-inferiority trial - not a superiority trial that found no significant differences. The authors must include a statement such as:

"The superiority of any single technique over the others was not demonstrated within the six-month follow-up period."

Comment 3 - "Conventional surgical approach" is an inappropriate term

The final sentence refers to conventional SSC placement as the "conventional surgical approach." SSC placement under the conventional technique involves tooth preparation and crown cementation - it is a restorative procedure, not a surgical one. The word "surgical" is inaccurate and should be replaced with "conventional restorative approach."

Comment 4 - "Showed a tendency toward greater acceptance" is an unsupported claim

The statement that minimally invasive techniques "showed a tendency toward greater acceptance" implies a trend that, while numerically present, was not statistically significant. If statistical significance was not reached, the authors cannot claim a tendency without reporting the effect size or confidence intervals that would support such a directional interpretation. This statement should either be supported with appropriate statistical measures or softened further.

Comment 5 - Follow-up duration qualifier missing

The Conclusions do not qualify their statements with the study's follow-up period in a consistent way. The opening sentence mentions "six-month follow-up," but the subsequent statements are written as broad generalizations without this qualifier. For example, "Gingival health and plaque accumulation remained within clinically acceptable limits" - this is only demonstrated for six months and should be stated as such throughout the Conclusions to avoid overgeneralizing.

Comment 6 - No clinical recommendation

A Conclusions section of a clinical trial should ideally offer a clear, qualified recommendation for clinicians. The current text stops at describing what was found but does not guide the reader on what to do with this information. A brief statement on clinical applicability - qualified by the study's limitations - would strengthen the Conclusions considerably.

Suggested Rewrite (for authors' consideration)

"Within the six-month follow-up period, stainless steel crowns placed using the Conventional Technique, Hall Technique, and Modified Hall Technique all demonstrated comparable clinical performance. No technique was found to be superior to the others with respect to crown retention, gingival health, plaque accumulation, or parental satisfaction. The Hall Technique and Modified Hall Technique represent viable, minimally invasive alternatives to the conventional restorative approach for managing carious primary molars, with the potential advantage of reduced procedural burden for the patient. These findings are limited to the short-term and should be interpreted with caution. Long-term, multicentre randomised controlled trials are needed to confirm the durability and biological outcomes of these techniques."

Overall Recommendation

With the corrections and revisions outlined across all sections of this review, the manuscript requires major revisions before it can be considered for publication. The most critical issues are:

The superiority framework contradiction
The factual error in Frankl's scale scoring
The misuse of the Wong-Baker FACES scale
The incorrect citation of Alpha/Charlie scoring as FDI criteria
The numerical discrepancy in parental satisfaction figures
The absence of a CONSORT flow diagram and baseline characteristics table
The absence of radiographic follow-up data for Hall Technique crowns

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