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GOOD MORNING

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ATRAUMATIC RESTORATIVE TREATMENT

SEMINAR

DEPARTMENT OF PUBLIC HEALTH DENTISTRY

PREPARED BY:-Dr. AMRITA RASTOGI

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History

Introduction

Definition

Goals

Principles of ART

Indication and contraindications.

Instruments and materials used.

Principal steps involved.

Restoring multiple surface Cavities Using ART

CONTENTS

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Selection of Teeth with Carious &Cavities Suitable for ART Sharpening dental instrument. Hygiene and Control of Cross Infection Monitoring restorations and sealants Advantages Limitations Community field studies with ART

Comparison of ART to conventional treatment Survival/ Retention of ART ART in public services Conclusion References

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In many countries, the caries process frequently progresses beyond the reversible stage and many people believe that loss of teeth is part of life. The main method of treating dental caries is extraction. The need to develop a new approach to oral care for use in economically less developed regions was reinforced by the World Health Organization (WHO). The ART was developed in Tanzania in mid-1980s as part of a community-based primary oral health program. The ART approach is based on minimal intervention and maximal prevention retaining sound tooth tissues.

INTRODUCTION 1,2,3

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The World Health Organization actively promotes atraumatic restorative treatment as a viable approach to meet the need for treatment of dental caries.

Atraumatic restorative treatment uses manual excavation of dental caries, which eliminates the need for anaesthesia and use of expensive equipment, and restores the cavity with glass ionomer, an adhesive material that bonds to the tooth structure and releases fluoride as it stimulates remineralisation.

Atraumatic restorative treatment is non-invasive, making it highly acceptable to patients.

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• Mid-1980s: Pioneered in Tanzania as part of a community-based primary oral health program by the University of Dar es Salaam.

1986: The results of the pilot study were presented at the scientific meeting of the Tanzanian Dental Association in 1986, and a minimal intervention approach, later called ART, was officially born.

HISTORY1,2,3,4

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• 1988: WHO Collaborating Centre for Oral Health Services

Research at the University of Groningen, the Netherlands

developed a model for primary oral health care for refugees and

displaced persons, which included treatment of caries by hand

instruments only.

1991: Community field trial to compare ART with the mobile

conventional equipment (cavity preparation-amalgam) approach

started in rural Thailand.

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1992: At the 6th-month evaluation of the Thailand study in

1992, it became very apparent that the children who had been

treated by ART happily participated, whereas those treated with

the traditional rotary hand piece approach were very reluctant

to do so.4

7th April 1994 : Official adoption of ART by WHO on “World

Health Day”.

By 1996: ART was being used in 25 countries.

2002: ART was adopted as one of examples of minimal

invasive dentistry, by FDI at the annual meeting in Vienna.3

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ART was developed by Dr. Jo Frencken DDS,

MSc, PhD, a dental researcher in the

Netherlands.

He was International Dentist-of-the-Year in

1999

His decade-long efforts promoting accessible

approach of cavity treatment to the Chinese

folks, Dutch oral health specialist Jo E.

Frencken has been awarded China’s

prestigious International Scientific and

Technological Cooperation Award on January

8 ,2016.

According to Prof. Frencken, "it is a low-tech

method to prevent and treat cavities, and it

can influence the lives of people in a very

pleasant way. That is very valuable. And it has

also a caries preventive component."

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DEFINITION2

American Academy of Pediatric Dentistry

“a dental caries treatment procedure involving the removal of soft, demineralized tooth tissue using hand instrument alone, followed by restoration of the tooth with an adhesive restorative material, routinely glass ionomer”.

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Goals 7

Avoiding discomfort.

Reducing

infection

Preserving the tooth structure

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Currently, ART is performed using glass-ionomer as the restorative material.

PRINCIPLE OF ART 5,6

•The two main principles of ART are:

•Removing the carious lesions using hand instruments.

•Restoring the cavity with a restorative material that sticks to the tooth.

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The reasons for using hand instruments rather than electric rotating hand pieces are: 8,9

- it makes restorative care accessible for all population groups.

- the use of a biological approach, which requires minimal cavity preparation that conserves sound tooth tissues causes less trauma to the teeth, the low cost of hand instruments compared to electrically driven dental equipment.

- the limitation of pain that reduces the need for local anaesthesia to a minimum and reduces psychological trauma to patients.

- simplified infection control. Hand instruments can easily be cleaned and sterilized after every patient.

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The reasons for using glass-ionomer are:

- as the glass-ionomer sticks chemically to both enamel and dentine, the need to cut sound tooth tissue to prepare cavity is reduced,

- fluoride is released from the restoration to prevent and arrest caries and,

- it is rather similar to hard oral tissues and does not inflame the pulp or gingiva.

For these reasons, ART provides preventive

and curative treatment in one procedure.

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In general ART is carried out only in the small and shallow cavities (involving the dentine ) that are accessible to hand instruments.

Introducing oral care to very young children, not previously exposed to dentistry.

For patients with extreme fear/anxiety.

INDICATIONS AND CONTRA-INDICATIONS FOR ART 10,11

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For the home-bound elderly and those living in nursing homes.

For mentally and/or physically handicapped patients.

In high-risk caries cases, as an intermediate treatment, to stabilize conditions.

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Contraindication There is presence of swelling (abscess) or fistula

(opening from abscess to the oral cavity)

near the carious tooth,

- the pulp of the tooth is exposed,

- teeth have been painful for a long time and there may be chronic inflammation of the pulp.

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- there is an obvious carious cavity, but the opening is inaccessible to hand instruments,

- there are clear signs of a cavity, for example in a proximal surface, but the cavity cannot be entered from the proximal nor the occlusal directions.

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Instruments and materials used. 12

MOUTH MIRROR

•Reflect light•Indirect view•Retract the cheek or tongue

EXPLORER•Identify the soft carious dentine

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PAIR OF TWEEZERS

•Carry cotton wool, rolls, pellets, wedges, and articulating paper.

SPOON EXCATATOR

•Used for removing soft carious lesions.•Small- diameter is about 1mm.•Medium- diameter is about 1.5 mm.

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DENTAL HATCHET• Use for

widening the entrance to the cavity.

APPLIER/CARVER

• Used for inserting the mixed GIC into cavity.

• To remove excess restorative materials.

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MIXING PAD AND SPATULA

• Mixing GICc

OPERATING LIGHT

The light source can be natural or artificial. Artificial light : more reliable, constant and can also be focused on a particular spot. In a field setting a portable light source is recommended e.g.

headlamp.

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ESSENTIAL MATERIALS FOR ART

COTTON WOOL ROLLS

• Use to absorb saliva

COTTON WOOL PELLETS

• Use for cleaning cavities.

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PETROLEUM JELLY

• Use to keep moisture away from

the GIC•Prevent sticking of

gloves to the GIC

PLASTIC STRIP

•Use for contouring the proximal

surface of multiple- surface restoration

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WEDGES • Use to hold the plastic strips close

GIC • Supplied as a powder and liquid.

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Others are :

Examination gloves

Mouth mask

Operation bed/ headrest extension stool

Methylated alcohol

Pressure cooker

Instrument forceps

Soap and towel

Sheet of textile

Sharpening stone

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1. ISOLATION

An important aspect for the success of ART is the control of saliva around the tooth being treated. Cotton wool rolls are quite effective at absorbing saliva and can provide short-term protection from moisture/saliva.

Principal steps involved 11,14,15

For teeth in the lower jaw For teeth in the upper jaw

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2. PREPARING THE CAVITYRemove plaque from the tooth surface

with a wet cotton wool pellet, and then dry the surface with a dry pellet.

Soft caries is removed using the excavator by making circular scooping movements - like using a spoon.

If the opening of the hole is narrow, widen the entrance of the cavity by placing the blade of the dental hatchet into the cavity and turning the instrument forward and backward like turning a key in a lock.

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Excavation is easy to do when the tooth is dry. Therefore, change saturated cotton wools for dry ones.

Carious dentine is removed with excavator by making circular scooping movements around the long axes of the instrument.

Overhanging enamel must be removed with the blade of the dental hatchet. Place the instrument at the edge of the enamel and fracture off small pieces.

After all the caries is removed from the cavity, it is cleaned with wet cotton wool

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In order to improve the chemical bonding of glass-ionomer to the tooth structures, the cavity walls must be very clean. It is not effective to do this with wet cotton wool pellets and therefore a chemical solvent is used. There are two possibilities:

- a dentine conditioner or tooth cleaner, especially developed for this purpose or

- the liquid supplied with the glass-ionomer itself.

3. CLEANING THE PREPARED CAVITY

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The dentine conditioner is usually a 10% solution of polyacrylic acid. Apply one drop of the conditioner on a pad or the slab. Dip a cotton wool pellet in the drop and then clean the entire cavity and adjacent fissures for 10-15 seconds. Do this holding the cotton wool pellets with a pair of tweezers. Then, immediately, wash the cavity and fissures at least twice with cotton wool pellets, dipped in clean water.

Application ofdentine conditioner

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The glass-ionomer liquid can be used for cleaning the cavity if it contains the same acid as is used for conditioning. Usually the liquid is too strong and needs to be diluted. This is done by placing one drop of liquid on a pad or slab. Then moisten a cotton wool pellet by dipping it in water.

It is advisable to dispense one drop for conditioning and a

second drop for mixing,keeping the bottle in the vertical

position between dispensing.

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Treatment Material

The material used for restoring cavities and sealing pits and fissures is glass-ionomer. This material must be used correctly for achieving good results.

Glass-Ionomer as a Restorative Material

CompositionThe material is supplied as a powder and liquid that must

be mixed together. The powder is a glass containing silicon-oxide, aluminium-oxide and calcium fluoride. The liquid is either polyacrylic acid or de-mineralized water.

4. MIXING OF RESTORATIVE MATERIAL

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Clinical Characteristics

Glass-ionomer bonds chemically to enamel and dentine and provides a good cavity seal.

- One of the most significant characteristics of glass-ionomer is the continued slow release of fluoride from the material after it has set. This helps prevent dental caries developing around the restoration.

- Glass-ionomer is not harmful to the pulp and gingiva. During setting, the material may cause the pulp to feel tender.

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-After 24 hours, when completely set, adverse

reactions do not occur anymore.

- Compared to established dental restorative materials, glass-ionomers have higher surface wear and lower strength.

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MixingIt is essential to closely follow the handling

instructions of the manufacturer particularly with respect to powder and liquid ratios. Place a spoonful of powder on the glass slab or mixing

pad.

Use the spatula to divide the powder into two equal portions, then dispense a drop of liquid next to the powder .

Hold the liquid bottle horizontal for a moment to allow air to escape from the tip. Move it to a vertical position and allow one drop of liquid to fall onto the slab.

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First spread the liquid with the spatula over a surface of about 1.5 cm2. Start mixing by adding one half of the powder into the liquid using the spatula. Roll the powder into the liquid gently wetting the particles without spreading them around the slab. As soon as all powder particles are wetted, the second portion is folded into the mix. Now mix firmly while keeping the mass together. The mixing should be completed within 20-30 seconds, depending on the brand of glass-ionomer used.

The final mixture should look smooth like chewing gum.

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Insertion of the mixture into the prepared cavity and over the remaining fissures must begin immediately. Use the applier/carver to place small amounts of the mixture into the cavity. This technique will avoid air being trapped between the floor of the cavity and the glass-ionomer (voids). The entire application procedure must be completed within 30-40 seconds.

5. RESTORING CAVITY

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Rub a small amount of petroleum jelly on the gloved index

finger and press the soft restorative material firmly into the

cavity and fissures and then slide the finger smoothly across

the occlusal surface of the tooth so that excess of GIC will get

deposited in remaining of fissures . THE PRESS-FINGER TECHNIQUE.

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The excess material is removed with a

carver.

Cover the ART restoration with a new

layer of petroleum jelly

The patient is not allowed to eat for at

least 1 hour.

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Dispense both powder and liquid onto the slab only when you have the cavity properly dried and protected from saliva.

Replace the lid of powder and liquid bottle carefully back into position immediately after use. This prevents uptake of moisture from the air or evaporation of the water component from the liquid.

If more than 30 seconds are used for mixing and the mixture looks dry, do not use it, because there will be poor adhesion to the tooth structure.

Each type of glass-ionomer may have its own specific needs. Therefore, follow the instructions of the manufacturers carefully.

THINGS TO REMEMBER

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Anterior teeth step-by-step

1. Work in a dry environment using cotton wool

rolls. Replace these as required.

2. Clean the cavity and ensure that the outline is

smooth and free of caries.

3.Place a plastic strip between the teeth and use

this to make the correct tooth contour of the

proximal surface.

4. Insert a soft wood wedge between the teeth

just at the gum margin to keep the plastic strip

firmly in position.

Restoring Multiple-Surface Cavities Using ART 14,15

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5. Condition the cavity as described for the one-surface cavity.

6. Mix the glass-ionomer as described before and insert it into the cavity until it is slightly overfilled.

7. Hold the strip tightly with the index finger on the palatal side of the tooth. Wrap the strip firmly around to the buccal side to adapt the restorative material well into the cavity. Hold the strip with the thumb on the buccal side for 1-2 minutes until the material has set firmly.

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8. Remove the strip and wedge, and cover the restoration with petroleum jelly.

9. Remove any excess material with the carver, check the bite with articulation paper and apply another coat of petroleum jelly.

10. Remove cotton wool rolls.

11. Ask the patient not to eat for one hour.

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A breakage in the tooth surface or a cavity in the tooth is recognized as decayed or carious tooth. With the probe gently and carefully go into the cavity, which will feel softer and may even be quite mushy.

The colour will vary from pale yellow in a new cavity to dark brown if it has been there a longer time.

Selection of Teeth with Carious& Cavities Suitable for ART. 8,9

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Just a change of the tooth surface does not necessarily mean it is caries. Sometimes, teeth can be discoloured because of staining due to some foods.

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Carious cavities are usually classified by the number of surfaces

affected. 10

One-Surface Cavities: These occur in only one surface of a

tooth, i.e.:

a. in pits and fissures on occlusal surfaces of premolars and molars.

b. in pits on lingual surfaces of upper incisors.

c. in buccal and lingual grooves of molars.

d. in buccal and lingual surfaces just above the gingiva of all teeth.

e. in proximal surfaces.

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a. Pits and fissures on occlusal surfaces of premolars and molarb. Pits on lingual surfaces of upper incisors

c. Buccal groove of lower molars

d. Buccal surfaces just above the gingiva.

e. Proximal surfaces of anterior teeth.

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Multiple-Surface Cavities

These affect two or more surfaces of a tooth, i.e.:

a. occlusal and proximal surfaces of premolars and molars,

b. occlusal, and buccal or lingual surfaces of premolars and

molars,

c. proximal, and buccal or lingual surfaces of anterior

teeth.

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a. Occlusal and proximal surfaces of a premolar and a molar.

b. Occlusal and lingual surfacesof a molar.

c. Proximal and buccal surfacesof an anterior tooth.

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Hand instruments used for cutting hard tooth

tissues, the excavator, dental hatchet and

carver, must be sharp to be effective.

A blunt instrument is a definite hazard, as it

requires excessive force to cut enamel and

dentine. The sharpness of the cutting edge

can be tested effectively on the thumbnail. If

the cutting edge digs in during an attempt to

slide the instrument over the thumbnail, the

instrument is sharp. If it slides, the instrument

is blunt. Only light pressure is exerted in

testing for sharpness.

Sharpening Dental Instruments 10,11

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Sharpening the Dental Hatchet and Carver A special flat stone, for example an 'Arkansas' stone, is

used for sharpening the hatchet, carver and spoon excavator. The procedure to follow is described below step-by-step.

1. Place the flat sharpening stone on a table. 2. Put a drop of oil on the stone. 3. Hold the stone firmly with one hand and rest the middle

finger of the other hand on the stone as a guide.4. Position the cutting edge of the hatchet or carver in the

oil parallel to the surface of the stone .5. Slide the instrument back and forth over the stone

several times for maximum sharpness. Take care that the surface to be sharpened stays parallel to the stone surface.

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Instruments should be sterilized after they have been sharpened.

Correct and incorrect position of dental hatchet for sharpening. Instrument must be held parallel to the flat surface of the sharpening stone. .

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Sharpening Spoon Excavator

Place the round surface of the excavator in the oil and make small strokes from the center of the round surface to the edge of the spoon. Do this in all directions so that the entire cutting edge is sharpened.

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If available, always wear gloves. Cleaning and disinfection of the working place and sterilization of instruments is essential to prevent infection passing from operator to patients and vice versa or between patients via the operator.

Cleaning and disinfection of surfaces in the working place can be done by using cotton gauzes impregnated with methyl spirit (alcohol).

In a clinic, instruments can be sterilized in an autoclave or a pressure cooker. If not in the clinic, a pressure cooker or a pan with a lid to boil the instruments can be used.

Hygiene and Control of Cross Infection13

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To avoid the risk of infection with diseases such as the human immunodeficiency virus (HIV) and hepatitis B virus (HBV), all instruments must be sterilized before being used for each patient.

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Operator’s position (Your

Position)

Operator should sit firmly on the

stool, with a straight back,

thighs parallel to the floor and

both feet flat on the floor.

The height of the stool should be

adjusted so that the operator can

see the patient’s teeth clearly.

OPERATOR'S WORK POSTURE AND POSITIONS 13,14

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Oral care is best provided by a team consisting of an operator and an assistant. However, assistance may not always be available. The assistance works at the left side of a right-handed operator and does not change position.

Operator’s posture

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Patient’s positionThe patient should lie on a flat surface that will

provide safe and secure body.

support and a comfortable and stable position for lengthy periods of time.

Patient’s position

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Patient’s head position

- Backward tilt lifting the chin for access to upper teeth.(a)

- Forward tilt dropping the chin for access to lower teeth.(b)

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Range of positions : 10 to 1 on the clock.

Most commonly used positions:

• direct rear position (12 o'clock) and

• right rear position (10 o'clock)

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• No restoration or sealant, irrespective of the material used, lasts

forever. Some restorations may last for many years, others may

fail earlier.

• Ask patients about pain felt during and after treatment, and their

overall satisfaction within a period of 4 weeks after being treated.

• First clinical evaluation - after half a year.

• Further evaluations : on an annual or biannual basis depending on

factors such as expected caries development, and the possibility of

sealing the individuals again.

Monitoring restorations and sealants

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Examine the tooth carefully for signs of caries.

If the surface is hard, leave it alone.

If the surface is carious, reseal or make a small restoration

depending on the extent of the defective sealant or of the

caries present.

For Failed or Defective Sealant

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A restoration may not be acceptable or unsatisfactory when1. it is completely missing,2. a large part of it has broken away,3. the restoration is fractured,4. much of the restorative material has worn away,5. caries has developed at the restoration margin or

elsewhere on the tooth surface.

Whatever the reason, clean the cavity completely, apply dentine conditioner and refill

the cavity according to the description .

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Use of easily available and relatively inexpensive hand

instrument rather than expensive electrically driven dental

equipment.

A biologically friendly approach involving the removal of only

decalcified tooth tissue which result in relatively small cavities

and conserve sound tooth structure.

The limitation of pain ,thereby minimizing the need for local

anesthesia.

Advantages 15

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A straight forward and simple infection control practice without

the need to use sequentially autoclaved hand pieces.

The chemical adhesion of GIC reduces the need to cut sound tooth

tissue for retention of the restorative material.

The leaching of fluoride from GIC prevent secondary caries

development and probably re mineralizes carious dentine.

The combination of a preventive and restorative treatment in one

appointment.

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The restoration can be easily repaired if damaged.

Low cost

ART may be used to restore and prevent caries in young

patient, uncooperative patients, or patients with special health

care needs or when traditional cavity preparation and/or

placement of traditional dental restoration is not feasible.

ART restoration can help maintain a natural tooth eruption

pattern and avoid disturbances in the position of permanent

teeth.

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Long-term survival rates for glass-ionomer ART restorations and

sealants are not available.

Use limited to small- and medium-sized, one-surface lesions because of

low wear resistance and strength of existing glass ionomer materials.

Hand mixing might produce an improper mix , varying among

operators.

Misapprehension that can ART can be performed easily-this is not the

case and each step must be carried out to perfection.

Possibility exists for hand fatigue from the use of hand instruments over

long periods.

Limitations15

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Treating dental caries using the ART approach without

emphasis on preventive measures is a job only half done.

Important to explain to people how they can prevent dental

caries from affecting other teeth.

1.  removal of plaque

2.  counseling on proper diet

3.  application of fluorides

4.  application of antimicrobial agents

5.  application of sealants

What not to forget?

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The ART approach was pioneered in Tanzania in the mid 1980

which was followed by several community field trials

conducted in Thailand ,Zimbabwe and Pakistan in 1991,1993

and 1995 respectively .Results of the studies in Thailand and

Zimbabwe have shown that 71% and 85% respectively of the

ART restoration remained in the teeth after 3 years.

Community field studies with ART 25,26

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Studies conducted in several countries showed high survival rates of atraumatic restorative treatment one-surface restorations, even in comparison with amalgam restorations. Median survival time of atraumatic restorative treatment is 5 years compared with 7 years for conventional amalgam restorations. The cost-effectiveness of atraumatic restorative treatment also has been established, 8–10 considering costs of equipment, materials, and wages. Atraumatic restorative treatment is currently used in 25 countries and is part of regular training programs for oral personnel in at least 3 countries.

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In a meta-analysis of 5 ART effectiveness studies, the retention

of ART restorations were compared to those using a

conventional method in single surface restorations in

permanent dentition with a follow-up of 2-3 years.

Only one study found that the survival rate of amalgams were

significantly higher than ART. 16

Comparison of ART to conventional treatment

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The 4 other studies found that the difference in survival in the

two techniques were not statistically different. The study with

the longest follow-up followed 152 school children for 6 years

who received either ART or conventional restorations. 17

The survival rate in ART treated surfaces after 6 years was

68.6% compared to 74.5% in conventionally treated surfaces;

this difference was not statistically significant. 18

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In clinical trials of ART compared to traditional treatment conducted by

the Pan American Health Organization (PAHO) in 3 South American

countries among children, the odds of failure for ART was 1.75 times

the odds of failure in amalgam composites, adjusting for age, sex and

country.19

One study by Steele et al looked at ART vs. conventional restorations in

the elderly (mean age 78.6 years), mostly 1-surface. After 12 months,

there were no statistical differences between the two types of

restoration in survival rates.20

A systematic review by Mickenautsch et al. concludes that ART can be

used in both primary and the permanent dentitions.21

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Survival rates of restorations using ART vary depending on

several factors.

In a meta-analysis of studies reporting survival rates of ART

restorations, single surface restorations were found to be more

successful than multi-surface restorations in both primary and

permanent dentition.

High viscosity glass-ionomer was retained longer than medium

viscosity.

Survival/ Retention of ART 20,21

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In a study in Kenya of 804 children 6-8 years old, overall

survival was 44.8% after 1 year. 22

Survival was highest if the cavities restored were 2-3 mm. 23

Frencken et alʼs Zimbabwe study in children over 3 years

found that experienced operators placed better, longer lasting

ART restorations than inexperienced ones. One-surface

survival rates were 88.3% in this study. 24

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Survival rates differ greatly between studies, but rates are hard to

compare because the populations differ so greatly.

A clinical field trial of 12-17 year-old Cambodian high school

students found that after 1 year 76.3% of restorations were still

successful and 57.9% were successful at 3 years. 25

118 children aged 5 to 18 years old in Mexico were given

sealants and/or restorations using ART. After 2 years, 66% of

restorations were retained. 26

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Lo et al. report a six-year follow up of ART in China,

concluding that smaller ART restorations survive longer than

larger restorations. 27

Overall, cavities restored using ART appear to be as effective

as conventional methods, most studies report that there is no

significant difference between the two methods.

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The first report that described the use of the ART approach in a

public service system originated from South Africa. ART was

introduced there mainly because of its appropriate economical

and restorative advantages and because of its patient

friendliness. The adoption of ART was associated with training,

research and follow-up supervision . Since then, the ART

approach has been proposed in several countries.

ART in the public services 26-34

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The Mexican experience of incorporating ART into the public

service stands out as a good example . It started with an ART

course in 1998, followed by the development and acceptance of a

National Oral Health Programme (including ART) and

subsequently, in 2002, a second ART course after which the

programme could commence fully. 28

It was estimated that 2 million ART procedures were performed in

the first six years of the programme, an increase of 400 % from

the baseline, and that 810 dentists had been trained in ART.29

The success of the restorations in primary and permanent teeth

was 82 % after 1 year. 30

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According to nine chief dental officers of 10 Latin American

countries, ART has been introduced into their countries‘ public

oral health service systems’, but the implementation is still in

its infancy.31

The implementation of ART in the public health services has

also been researched in Tanzania. ART introduction resulted in

an increase in the mean percentage of total restorations in

relation to total treatment rendered, from 3.9 % at baseline to

13 % at the end of the 31-month study period.32

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The experiences in South Africa, Mexico, Tanzania, the

Latin American countries and Cambodia show that the

proper implementation of ART in the public oral health

services is mainly hampered by two factors: the

availability of ART instruments and the availability of

quality glass ionomers.33

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Strategies for successful incorporation of ART into public

oral health services should, therefore, include organisation

of training courses in ART for trainer dentists, in addition

to regular complete ART courses in countries that have

already organised such courses; support for course

participants through ensuring the constant supply of

quality high viscosity glass-ionomer restorative material.

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Brazil 34

Atraumatic Restorative Treatment (ART) for a disadvantaged Brazilian Community:

“Training oral health personnel In October 2001, three oral health teams were included in the Family Health Programme in this area. These teams and other dentists in the public health network were trained by a university teacher in the area, to perform ART restorations using glass ionomer cement.”

Examples of ART programmes from different countries presented in the WHO Oral Health database(2008)

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South Africa 36

Introducing the Atraumatic Restorative Treatment (ART) approach in South “Refugee Services:

In 1997, twelve lay refugees in the Liberian refugee camp were trained in basic oral health care including ART according to WHO training module. This primary oral health programme for refugees were revisited after 3 years in December 1999. The 12 trained refugees maintained an oral health clinic in the camp, where patients were treated with ART”.

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Sri Lanka 38

Atraumatic Restorative Treatment (ART) Programme in Sri Lanka:

“Once a month a team of dentists and about 10 dental students

from the Division of Community Dentistry visit a primary school

in the Kandy area. The Faculty receive requests from the

Principals of schools, mainly from impoverished areas where

the schoolchildren otherwise will not receive any dental care.

The students supervised by the doctors, carry out the

examination and treatment in a well-lit classroom or outside in

the school premises. While the children are waiting for

treatment, they are given oral health education by the dental

students. ART is carried out on about 25-30 children on one

visit. Around 250 students are provided with ART per year”.

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Turkey 39

Atraumatic Restorative Treatment (ART) Programme in some rural areas of Turkey:

“Dentists and often dental students visit the rural areas including Bagivar, a small town and Anatolia. ART restorations are performed in school children, farm worker's children living in tents or children working in cotton fields”.

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Atraumatic Restorative Treatment (ART) is a minimally invasive approach to both prevent dental carious lesions and stop its further progression. It consists of two components :sealing of carious-prone pits and fissures(ART sealants) and restoration of cavitated dentin lesions with sealant-restorations (ART restorations).

ART is sometimes criticized because it is seen as being merely a restorative treatment performed by dentists but It is not only a restorative but also a preventive and palliative treatment,

Conclusion

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performed not only by dentists but also by other operating dental personnel, such as dental therapists also it can be performed by person without any dental education background if given proper training for example Bare foot doctors, are farmers who received minimal basic medical and paramedical training and worked in rural villages in the People's Republic of China. Their purpose was to bring health care to rural areas where urban-trained doctors would not settle . This increases the chance for better oral health in underserved communities in both developed and developing countries.

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1. Jo E. FRENCKEN Evolution of the ART approach: highlights and achievements J Appl

Oral Sci. 2009; 17(sp. issue):78-83

2. http://www.biomedcentral.com/1472-6831/13/42 Elisa Luengas-Quintero , Jo E

Frencken , Jorge Alejandro Muñúzuri-Hernándezand Jan Mulder The atraumatic

restorative treatment (ART) strategy in Mexico: two-years follow up of ART sealants

and restorations BMC Oral Health 2013, 13:42

3. Jo E. Frencken Christopher J. Holmgren Caries management through the Atraumatic

Restorative Treatment (ART) approach and glass-ionomers: update 2013 Braz Oral

Res., (São Paulo) 2014;28(1):1- 4

4. Eduardo BRESCIANI CLINICAL TRIALS WITH ATRAUMATIC RESTORATIVE

TREATMENT (ART) IN DECIDUOS AND PERMANENT TEETH J Appl Oral Sci.

2006;14(sp.issue):14-9.

REFERENCES

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5. Naty Lopez, Sara SimpserRafalin , and Peter Berthold.

Atraumatic Restorative Treatment for Prevention and Treatment of Caries in an Underserved Community American Journal of Public Health | August 2005, Vol 95, No. 8

6. Saskia Estupiñán-Day,Marisol Tellez, Sundeep Kaur, Trevor Milner,and Alfredo Solari Managing dental caries with atraumatic restorative treatment in children: successful experience in three Latin American countries Panam Salud Publica 33(4), 2013.

7. Dr. Jo Frencken , Dr. Evert van Amerongen ,Prof. Prathip Phantumvanit ,Dr. Yupin Songpaisan ,Prof. Taco Pilot MANUAL FOR THE ATRAUMATIC RESTAURATIVE TREATMENT APPROACH TO CONTROL DENTAL CARIES ISBN 90-803296-1-4

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8. Palwasha Momand, Jayanthi Stjernswärd How to carry out Atraumatic RestorativeTreatment (ART) on decayed teeth - A Training Manual for Public Health Workers 2008.

9. C. J. Holmgren, D. Rouxand S. Doméjean Minimal intervention dentistry:part 5. Atraumatic restorative treatment (ART) – a minimum intervention and minimally invasive approach for the management of dental caries BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013.

10. Peter S. Essentials of preventive and community dentistry. 2nd edition, 2005. Arya publications.

11. Mickenautsch Sand Grossman E S Atraumatic restorative treatment (ART) – factors affecting success Journal Of Minimum Intervention In Dentistry 2008; 1 (2) Iowa Research Online: http://ir.uiowa.edu/etd/2912

12. Elham Talib Kateeb Factors related to the use of atraumatic restorative treatment (ART) in pre and post-pediatric dentistry programs and in pediatric dentistry practices in the US 2012.

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13. Roger J Smales, Hak-Kong Yip The atraumatic restorative treatment

(ART) approach for primary teeth: review of literature American Academy

of Pediatric Dentistry May 12, 2000

14. Van Amerongen WE, Rahimtoola S. Is ART really atraumatic? Community

Dent Oral Epidemiol 1999;27:431-5.

15. Mjor IA, Gordon VV-A review of atraumatic restorative treatment (ART),

Int Dent J: 1999 Jun;49(3):127-31.

16. Smales RJ. Yip HK. The atraumatic restorative treatment (ART) approach

for the management of dental caries. Quintessence Int 2002;33:427-32.

17. Atraumatic Restorative Treatment (ART): Recent Development and

Application. J Pub Health Dent 1999, 43(2): 32-9.

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18. Pilot T. Introduction – ART from a global perspective.

Community Dent Oral Epidemiol 1999;27:421-2.

19. Yip HK, Smales RJ. Glass ionomer cements used as fissure

sealants with the atraumatic restorative treatment (ART)

approach: review of literature. Int Dent J 2002;52:67-70

19. Kemoli, A.M. and W.E. van Amerongen, Influence of the

cavity-size on the survival rate of proximal ART restorations

in primary molars. Int J Paediatr Dent, 2009. 19(6): p. 423-30.

20. Frencken, J.E., et al., Effectiveness of Single-surface ART

Restorations in the Permanent Dentition: A Meta-analysis.

Journal of Dental Research, 2004. 83(2): p. 120-123.

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21. Kalf-Scholte, S.M., et al., Atraumatic restorative treatment (ART): a

three-year clinical study in Malawi--comparison of conventional

amalgam anARTrestorations. D J Public Health Dent, 2003. 63(2): p.

99-103.

22. Phantumvanit, P., et al., Atraumatic restorative treatment (ART): a

three-year community field trial in Thailand--survival of one-surface

restorations in the permanent dentition. J Public Health Dent, 1996.

56(3 Spec No): p. 141-5; discussion 161-3.

23. Taifour, D., et al., Comparison between restorations in the permanent

dentition produced by hand and rotary instrumentation--survival after

3 years. Community Dent Oral Epidemiol, 2003. 31(2): p. 122-8.

24. Mandari, G.J. and M.I. Matee, Atraumatic Restorative Treatment

(ART): theTanzanian experience. Int Dent J, 2006. 56(2): p. 71-6.

05/01/2023 104

25. Rahimtoola, S. and E. van Amerongen, Comparison of two tooth-saving preparation techniques for one-surface cavities. ASDC J Dent Child, 2002. 69(1): p. 16-26, 11.

26. PAHO: Oral health of low income children. Procedures for Atraumatic Restorative Treatment. In Final Report Pan American Health Organization, Washington DC;2006

27. Steele, J., ART for treating root caries in older people. Evid Based Dent, 2007.8(2): p. 51.

28. van 't Hof, M.A., et al., The atraumatic restorative treatment (ART) approach formanaging dental caries: a meta-analysis. Int Dent J, 2006. 56(6): p. 345-51.

29. Kemoli, A.M. and W.E. van Amerongen, Influence of the cavity-size on the survival rate of proximal ART restorations in primary molars. Int J Paediatr Dent, 2009. 19(6): p. 423-30.

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30. Mallow, P.K., C.S. Durward, and M. Klaipo, Restoration of permanent teeth in young rural children in Cambodia using the atraumatic restorative treatment (ART) technique and Fuji II glass ionomer cement. Int J Paediatr Dent, 1998.8(1): p. 35-40.

31. Lopez, N., S. Simpser-Rafalin, and P. Berthold, Atraumatic restorative treatment for prevention and treatment of caries in an underserved community. Am J Public Health, 2005. 95(8): p. 1338-9.

32. Chalmers, J.M., Minimal intervention dentistry: part 2 Strategies for addressingrestorative challenges in older patients. J Can Dent Assoc, 2006. 72(5): p. 435-40.

33. Mickenautsch, S., I. Munshi, and E.S. Grossman, Comparative cost of ART andconventional treatment within a dental school clinic. SADJ, 2002. 57(2): p. 52-8.

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34. Mickenautsch, S, Yengopal V, Banerjee A. Atraumatic restorative

treatment versus amalgam restoration longevity: a systematic

review. Clin Oral Investig 2010; 14:233-40.

34. Lo EC, Holmgren CJ, Hu D, van Palenstein Helderman W. Six-year

follow up atraumatic restorative treatment restorations placed in

Chinese school children.Community Dent Oral Epidemiol 2007;

35:387-92

35.http://www.whocollab.od.mah.se/amro/brazil/data/brazilart.html.

36. http://www.whocollab.od.mah.se/expl/artsa.html

37.(

http://www.whocollab.od.mah.se/searo/srilanka/data/srilankaart.ht

ml

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38. (http://www.whocollab.od.mah.se/euro/turkey/data/turkeyart.html)

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THANK YOU