Dental Health International Nederland
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Chapter 2 - ART: What One Should Know
ART is not suitable for all tooth cavities.
A proper diagnosis of cavities which can and cannot be treated, is essential for the successful treatment of caries. This chapter presents the principles of the ART approach and indicates where the approach will be most successful.
Principles of ART
The two main principles of ART are:
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- removing carious tooth tissues using hand instruments only, and
- restoring the cavity with a restorative material that sticks to the tooth.
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Currently, ART is performed using glass-ionomer as the restorative material.
The reasons for using hand instruments rather than electric rotating handpieces are:
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- 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 and
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:
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- as the glass-ionomer sticks chemically to both enamel and dentine, the need to cut sound tooth tissue to prepare the
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.
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For these reasons, ART provides preventive and curative treatment in one procedure.
Identification of Carious Cavities Suitable for ART
In the previous chapter, the stages in the development of dental caries have been described.
In general, ART can be applied when:
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- there is a cavity involving the dentine, and
- that cavity is accessible to hand instruments.
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ART should not be used when:
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- 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,
- 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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What percentage of carious cavities can one expect to be inaccessible and where are these situated in the mouth.
In a study carried out among 14-year-old children in Zimbabwe, 16% of the cavities in permanent teeth could not be treated with ART. Cavities with suspected or definite pulpal involvement were not included in this number. Most of the cavities which could not be treated were found in proximal surfaces only, particularly in front teeth.
Carious cavities are usually classified by the number of surfaces affected.
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.
Examples of these situations are illustrated in figure 2.1
Figure 2.1
Various types of one-surface carious cavities
a. Pits and fissures on occlusal
surfaces of premolars and
molars.
b. 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.
Examples of these situations are illustrated in figure 2.2.
Figure 2.2
Various types of multiple-surface carious cavities.
a. Occlusal and proximal surfaces of a premolar and a molar.
b. Occlusal and lingual surfaces of a molar.
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c. Proximal and buccal surfaces of an anterior tooth.
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Application of ART
Based on studies already conducted, ART can certainly be used with confidence in one-surface cavities particularly in permanent teeth. For example, results of field studies in Thailand and Zimbabwe have shown that 71% and 85% of the one-surface ART restorations respectively, are in good shape after three years. It is expected that ART will perform equally well in one-surface cavities in primary teeth. Unfortunately, limited information is available at the moment to support this assumption. In primary teeth, ART restorations do not need to stay in place for long since these teeth will eventually be replaced by permanent teeth. The maximum time a restoration needs to remain in a primary tooth is about 6 years. ART restorations can help maintain a natural tooth eruption pattern and avoid disturbances in the positions of permanent teeth.
Success of ART in multiple-surface cavities very much depends on the size of the cavity and the restorative material used. Small to medium size multiple-surface cavities can be confidently treated with ART. Restorations placed in large cavities may not stay in place for a long time. This is because the glass-ionomers currently available are not strong enough for this application. However, glass-ionomers with improved qualities are being developed. We can expect in the future that improved materials appropriate for use in large size cavities will become available.
As ART does not require electrical driven dental equipment, carious cavities can be treated almost everywhere. ART can be applied, not only in the dental clinic, but also in institutions for home-bound, physically and mentally handicapped people, in remote areas and in schools. It is certainly patient friendly and makes the provision of oral care much easier to patients who are nervous or fearful.