Simplified and Modified Atraumatic Restorative Treatment

(SMART)

Prepared by :Gholami hamed

Introduction:

• SMART: a Simplified and Modified Atraumatic Restorative Treatment is a method to remove caries and minimal cavity preparation using only hand instruments and fill it with glass ionomer cement, can be applied to restorative treatment of primary teeth.

• the method is showed to obtain sufficient effect comparable to composite resin fillings and amalgam fillings , without inducing fear of children.

• SMART. is a slow and gentle technique that is well tolerated by the most fearful of patients. It is more comfortable than standard techniques. No injections or powered drills are needed. Young children do very well with it

Applications:

• Good alternative in field conditions

• Excellent for fearful children

• Good alternative in medically compromised patients

• Good alternative in mentally compromised

childs

Principles of SMART

A. removing carious tooth tissues using hand instruments only

B.restoring the cavity with a restorative material that sticks to the tooth.

cavities suitable for SMART:

1.involving dentin

2. accessible to hand instruments

3.one surface more than multiple surface cavities

contraindications:

a.pulp disease at sequellae chronic or irriversible pulpitis

pulpul exposure

abscess or fistula

b.inaccessible to hand instruments

instruments:

Mouth mirrorExplorerPair of tweezersDental hatchetSpoon excavator, smallSpoon excavator, mediumSpoon excavator, largeApplier/carverGlass slab or paper mixing padSpatula

Materials:

Cotton wool rollCotton wool pelletClean waterGlass-ionomer restorative material liquid, powder and measuring spoonDentine conditionerPetroleum jelly WedgePlastic stripArticulation paper

Outhers:

Examination glovesMouth maskOperating lightOperation bed / headrest extensionStool Methylated alcoholPressure cookerInstrument forcepsSoap and towelSheet of textileSharpening stone and oil

basic techniques:

a.good working invirinment

b.patient positioning

c.operator positioning

d.correct instruments

e.infection control

f.GIC material

Why glass ionomer?

bonds to enamel and dentin

fluoride release

Ease to use

instruments:

A small enamel hatchet used to open access to underlying softened dentine

Two spoon-shaped excavators, one small with a spoon approximately 1 mm across, another slightly larger are used to excavate soft dentine

A small flat plastic instrument is used for applying the GIC and for shaping the restoration.

An Enamel Access Cutter (EAC) can be used to access the cavity when the enamel hatchet is too large

The instruments are laid out in the sequence that they are going to be used

operative procedures:

• PREPARING THE CAVITY

a. Place a cotton roll and dry the working tooth.

b .Use the dental hatchet to gain access and excavators to remove soft caries and unsupported enamel.

It is very important that:

1. All soft caries is removed at enamel-dentinejunction.

2. To avoid exposure of pulp in deep cavities, leave asmall portion of affected dentine near pulp region

The smallest excavator is used to remove soft dentine from the enamel dentine junction by making circular scooping movements under the enamel

Where more access is required, some of the enamel can be gently fractured off with the blade of the hatchet along the line of the enamel prisms

• CLEANING THE PREPARED CAVITY

The purpose of cleaning the cavity walls is to improve chemical bonding of GIC to toothstructure.

Cavity could be cleaned by:

1. Dentine conditioner (10% Polyacrylic acid)

2. The liquid supplied by GIC itself. With dentine conditioner clean the cavity walls for10-15 seconds and dry with cotton wool pellets.

Repeat the procedure if contaminated by blood or saliva

The GIC is inserted into the cavity in small increments using the rounded end of the applier/carver instrument.

Slightly overfill the cavity and then place additional GIC in any pits and fissures adjoining the cavity

• RESTORING THE CAVITY

After cavity is washed and dried, start mixing GIC powder and liquid.

Insert in small amounts using applier/carver to avoid air bubbles and build the restoration slightly high on occlusal surface.

Insert material into corners and unsupported enamel first. With petroleum jelly on the gloved index fingerpress the soft material into the cavity, this iscalled “the press-finger technique”.

Do not disturb the restoration during hardening phase.

The tip of the index finger is then placed onto the central part of the restorations to enable the GIC to be pressed firmly into the cavity, pit and fissures

After 1-2 minutes check the occlusion.

If the restoration too high, remove the stained portion of restoration with a carver blade.

The finished restoration is then covered with petroleum jelly or varnish and the patient advised not to eat for at least one hour

A completed restoration sealant

Glass-Ionomer Used as a Sealant

It is not always easy to see early dental caries. Its progression can be rapid, particularly in young people who have already untreated cavities and/or restorations.

If nothing is done, early dental caries can develop to a cavity in less than 1 year.

Sealing pits and fissures with glass-ionomer can

control dental caries and prevent it from occurring.

The presence and viability of microorganisms

under pit and fissure sealants has bee investigated.

It has been shown that when the sealant remain intact, the number of viable microorganisms left beneath the sealant decreases with time.

The destructive activity of the remaining bacteria is reduced, leaving the bacteria incapable of causing tooth destruction.

This is logical since remaining bacteria are now cut off from their source of nutrients.

There is convincing evidence that pit and fissure sealants are capable of arresting the carious process.

Even when glass-ionomer sealants have been partly or completely lost, there is usually a benefit to the patient because the fluoride released from the material will have made the enamel harder.

Indications:

As glass-ionomer sticks chemically to enamel, it is useful as a sealant. It also releases fluoride into the enamel and this may stop development of caries.

Experience has shown that sealants of glass-ionomer remain in the deeper pit and fissures that are most at risk for decay. In contrast, sealants may be lost rather quickly in shallow pits and fissures

Procedures:

notice:

Place the sealant only in the pit and fissures. Take care not to cover the cusps of the tooth

1. Isolate the tooth with cotton wool rolls. Keep the treatment area dry.

2. Clean the surface from debris with a cotton wool pellet dipped in water.

3. Gently remove debris from deepest parts of pit and fissures with an explorer

4. Apply dentine conditioner or diluted glass-ionomer liquid into the pits and fissures for 10-15 seconds

5. Immediately wash the pits and fissures, using wet cotton wool pellets to clean off the conditioner. Wash 2-3

times.6. Dry the pits and fissures with cotton wool

pellets.7. Mix the glass-ionomer and apply it in all

pits and fissures with the blunt blade of the applier/carver. Overfill slightly.

8. Rub some petroleum jelly on the gloved index finger.

9. Put the index finger on the mixture, press and remove finger sideways after a few seconds.

10. Remove visible excess of mixture with a large excavator

11. Wait 1-2 minutes till the material feels hard, while keeping the tooth dry.

12. Check the bite using the articulation paper and adjust the amount of sealant with the carver if needed.

13. Apply a new layer of petroleum jelly.14. Remove cotton wool rolls.15. Ask the patient not to eat for at least one

hour