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Atraumatic Restorative Treatment (ART) for tooth decay

IntroductionAtraumatic Restorative Treatment (ART), is based on removing decalcified tooth tissue using only hand instruments and restoring the cavity with an adhesive filling material.

A minimally invasive approach to both prevent dental carious lesions and stop its further progression.

Initiated in the mid-eighties in Tanzania in response to an inappropriately functioning community oral health programme that was based on western health care models and western technology.

It consists of two components:

sealing of carious-prone pits and fissures (ART sealants)

restoration of cavitated dentin lesions with restorations (ART restorations)

Adoption of ART by the World Health Organization on World Health Day, in 1994 as an effective and efficient method of caries control.

This technique has achieved considerable interest worldwide both in,

developing countries where skilled human and other resources are not readily available underserved communities in the industrialized world who are unable to afford for care for dental caries by more conventional means.

Carried out in the absence of electricity, pipe water and anesthesia.

Performed not only by dentists but also by other operating dental personnel, such as dental therapists.

This increases the chance for better oral health in underserved communities in both developed and developing countries.

Minimize oral health related inequalities.

Introduced in to clinical setting in 1990s

Acceptable method to treat anxious patients with minimal discomfort and pain.

Carious process in a teeth

Indications for ARTWhere conventional restorative procedures are impossible

Anxious children and adults

Patients who are physically/medically/mentally handicapped

Cavitated tooth

Cavity could be reached with hand instruments

Contraindications for ARTPresence of swelling or fistula in relation to the teeth.

Tooth with pulp exposure

Painful tooth for a long time which probably involves the pulp

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

There are clear signs of a cavity, eg: in a proximal surface, but the cavity cannot be entered from the proximal or the occlusal direction

Instruments and Materials essential for ARTInstruments

MOUTH MIRROREXPLORER/PROBEPAIR OF TWEEZERSEXCAVATORDENTAL HATCHETAPPLIER/CARVERMIXING-PAD and SPATULA

Materials

GLASS-IONOMER CEMENTDENTINE CONDITIONERCOTTON WOOL ROLLSCOTTON WOOL PELLETSPETROLEUM JELLYPLASTIC STRIPWEDGES

ART steps1. Arrange a good working environment Outside the mouthOperators posture and position Assistance Patient position Operating light

Inside the mouth Control of Saliva

2. Hygiene and Control of Cross Infection

Always wear gloves and mask. Cleaning and disinfection of the working place and sterilization of instruments.Place all instruments in water immediately after use.Remove all debris from the instruments by scrubbing with brush in soapy water.If an autoclave is available, follow the manufacturer's instructions carefullyIf a pressure cooker is available, prepare fire using the fuel available - wood, gas, charcoal, solar energy.Put the clean instruments in a pressure cooker and add clean water to a depth of 2- 3cm from the bottom and boil.

3. Caries removal

Remove soft superficial carious tissues with the spoon excavator.Not necessary to prepare a cavity.If the opening of the hole is narrow, widen the entrance of the cavity by placing the blade of the dental hatchet If TF is in place remove it completelyAfter all the caries is removed from the cavity, it is cleaned with wet cotton wool/water syringe.

4. Conditioning the cavity

In order to improve binding of the material to the tooth surface, smear layer on the dentine is removed .

The surface is therefore cleaned with dentine conditioner- 10% Polyacrylic acid/GIC liquid

Apply one drop of conditioner on a mixing pad or slab.

Hold a cotton wool pellet with a pair of tweezers and dip it in the drop and then clean the entire cavity for 10-15 seconds.

Immediately wash the cavity at least twice with cotton wool pellets, dipped in clean water.

Dry the cavity with dry cotton wool pellets.

5. Mixing the material

Follow the instruction according to the manufacturer. Place a scoop of the powder on a mixing pad Use the spatula to divide the powder into two equal portions, and then put a drop of liquid next to the powder. Spread liquid on the mixing pad with the spatula and start mixing by adding one half portion of the powder into the liquid. As soon as the powder particles are wetted the second portion of the powder is included into the mixture. Mixing should be completed within 20-30 sec.Final mixture should look smooth, glossy and putty type.

6. Placing the filling material

Insert the material into the cavity with a filling instrument and plug with slight pressure. Slightly overfill. (ART restoration)

Spread additional material on the occlusal surface to cover pits and fissures (ART sealant).

Rub some petroleum jelly on the gloved index finger and place the index finger on the restorative material, press and remove finger sideways after a few seconds.

Remove visible excess of glass-ionomer with a carver and free the occlusion.

Cover the entire surface with a cavity varnish. Avoid eating or drinking for one hour.

Success rates of ART (WHO report 1993)After 12 months, Class II/multisurface and Class III/IV ART restorations have generally shown success rates of approximately 55-75% and 35-55% respectively.

Failures were usually from restoration losses and fractures.

Class I & V/single-surface ART restorations have had much better short-term success rates of approximately 80-90%.

Advantages of the ART techniqueART is a biological approach that requires minimal cavity preparation and conserves sound tooth tissues.

The need for local anesthetics are reduced and reduces the psychological trauma to the patients

Simplifies infection control as hand instruments can easily be cleaned and sterilized

No electrically driven and expensive dental equipment needed which enables ART to be practiced in remote areas and in the field

This technique is simple enough to train non-dental personnel or primary healthcare workers

cost effective

For use among children, fearful adults, physically and mentally handicapped patients.

Cariostatic property of GIC. Control caries progression.

Ease of repair of restorations.

Limitations of the ART techniqueUnable to perform in inaccessible cavities.

Inferior mechanical and physical properties of the filling material in compared to Amalgam and composite.

Not suited for deep cavities with pulp exposure or potential to expose pulp.

Hand fatigue for the operator.

Time consuming.

Examples of ART programmes from different countries presented in the WHO Oral Health database (2008)Atraumatic Restorative Treatment (ART) for a disadvantaged Brazilian Community

Introducing the Atraumatic Restorative Treatment (ART) approach in South Africa. In 1997, twelve lay refugees in the Liberian refugee camp were trained in basic oral health care including ART according to WHO training module. The 12 trained refugees maintained an oral health clinic in the camp, where patients were treated with ART.

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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