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Dental Health International Nederland
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Basic Package of Oral Care
Jo E. Frencken
Christopher J. Holmgren
Wim H. van Palenstein Helderman
WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios
Chapter 4 - Atraumatic Restorative Treatment (ART) for the management of dental caries
Atraumatic Restorative Treatment (ART) is an appropriate approach to the treatment of dental caries because it is not limited to the confines of a dental clinic. ART thus increases affordability, availability and accessibility of dental treatment. ART has
been demonstrated to be effective for the management of single-surface cavities and for fissure sealants. It is acceptable to patients. As such, the approach complements primary caries preventive methods as part of a basic package of oral care.
Introduction
While preventive methods, such as affordable fluoride toothpaste, continue to make a large impact on the level of caries, some carious lesions inevitably progress to cavitation. In the absence of restorative treatment, this leads to pain, infection and ultimate loss of the tooth.
Conventional restorative treatment approaches rely heavily on electrically driven equipment that is expensive and difficult to maintain. Moreover, the complexity of the equipment required usually restricts the treatment setting to a dental clinic. Thus, conventional restorative treatment for many non-EME countries and communities has been shown to be impractical on the grounds of cost, availability and accessibility.
Atraumatic Restorative Treatment (ART) is a novel approach to the management of dental caries that involves no dental drill, plumbed water or electricity. The approach consists of manually cleaning dental cavities using hand instruments. The cavities and adjacent fissures are filled with an adhesive, fluoride-releasing restorative material. An ART sealant can be applied in pits and fissures with evidence of enamel caries but without cavitation. The ART approach is entirely consistent with modern concepts of preventive and restorative oral care, which stress maximum effort in prevention and minimal invasiveness of oral tissues. Moreover, since all sound tooth tissue is retained during the cleaning of the cavity, pain and discomfort are rare during treatment, virtually eliminating the need for an anesthetic. The elimination of the need for a dental drill or local anesthesia with ART means the approach is extremely well accepted even by young children who have never had dental treatment before.
Appropriately trained dental auxiliaries, such as dental therapists, can perform ART at the lower level of the health care pyramid, such as in health centers and in schools. This makes restorative treatment more affordable, while simultaneously making it more available and accessible. ART, therefore, meets the principles of PHC: prevention (through secondary prevention), appropriate technology, affordable treatment and equitable distribution of services. A textbook on ART, by Frencken and Holmgren, provides a detailed, step-by-step description of the ART approach.
Effectiveness of the ART approach
The effectiveness of hand instruments for opening tooth cavities has been studied. In Zimbabwe adolescents belonging to a low-caries risk group, it was possible to gain access to tooth cavities with a dental hatchet in 84 percent of the dentinal lesions judged to be in need of treatment. Dentinal lesions in approximal surfaces of anterior teeth, however, were judged to be difficult to treat using ART.
In Syria, in a younger age group (6-8-year olds) with high-caries risk, it was possible to treat at least 90 percent of the dentinal lesions in the primary dentitions. The comparable figure in the permanent dentition in this age group was 54 percent.
The use of excavators for removing infected carious dentine was in use long before the advent of rotary instruments and their effectiveness has been clearly demonstrated.
Survival of ART restorations
Current research on the ART approach has mainly investigated the approach in single-surface carious cavities using glass ionomer as a restorative material. In earlier ART studies a low-stress-bearing glass ionomer (ChemFil, ChemFil Superior, Fuji II) was used. More recent studies have used a medium-stress-bearing glass ionomer specifically developed for the ART approach (Fuji IX, KetacMolar, ChemFlex).
The use of the ART approach for the restoration of multiple-surface carious cavities using glass ionomer should be carefully considered. Studies evaluating multiple-surface ART restorations are currently being carried out. The indication for the use of ART is currently limited to single-surface carious cavities. Therefore, in order to ensure consistent and reliable results with ART, careful selection of cases and restorative materials is required.
How good are ART restorations in the permanent dentition?
The majority of studies evaluating ART restorations have been made in the permanent teeth of adolescents. At this age, dentine caries are most common in pits and fissures. Hence the studies that are presented in Figure 4.1 refer only to single-surface ART restorations of longer than one year.
With the exception of the earlier studies, when the ART approach was still being developed, it can be concluded that the one-year survival rate of single-surface ART restorations used in permanent dentition lies between 95 and 100 percent and that the two- and three-year survival rates lie between 92 and 94 percent and 85 and 89 percent, respectively. When ART restorations from the 1996-1999 China study were classified into "small" restorations (less than half the occlusal width) and "large" restorations (greater than half the occlusal width), the three-year survival percentages were 92 percent and 77 percent, respectively. The overall results suggest that the average annual failure rate for ART restorations is about 4-5 percent for the first three years.
ART restorations vs. conventional restorations
Permanent dentition
As with all restorative procedures, survival is influenced by many factors. These include the caries risk profile of the population, the practice environment, the operator and the materials used. Numerous studies have assessed the quality of amalgam and composite resin restorations. Comparisons between studies are difficult because of diverse study designs, evaluators and evaluation criteria. Therefore, only estimates can be made about the average life span of an amalgam and composite resin restoration in general dental practice. Survival of these types of restorations varies considerably and ranges from five to more than 20 years. The outcomes from conventional restorations are considered the reference point to which the ART restorations should be compared. A few
studies have compared restoration survival of ART to that using the conventional approach. The studies were conducted among school children in Malawi, Tanzania, Pakistan and Syria and among school children and adults in Thailand. The results of these studies are presented in Figure 4.3.
There was no statistically significant difference reported between the survival of conventionally placed amalgam and ART restorations using glass ionomers in single-surfaces after one year in Malawi and two years in Pakistan and Tanzania. Only in the earlier Thailand study was a statistically significant difference reported between the survival of conventionally placed amalgam and ART restorations in single-surfaces after three years. The amalgam restorations performed better. However, recent results from Syria showed no statistically significant difference between single-surface ART and amalgam restorations after three years. These findings indicate that ART restorations in single-surfaces in permanent teeth perform as well as conventional amalgam restorations. However, these short-term findings should be confirmed in longer-term comparative studies.
Primary dentition
Only one study has investigated the difference between ART restorations using a medium-stress-bearing glass ionomer and conventional amalgam restorations in the deciduous dentition. The three-year survival of single-surface ART and amalgam restorations in Syrian school children were 86 percent and 80 percent, respectively. This difference was statistically significant in favor of ART. The survival outcomes for single-surface ART restorations in primary teeth longer than one year are shown in Figure 4.2.
The three China studies show differences in results over two years, although the newer improved glass ionomers were used in all three studies. In the first two studies in China, where lower survival rates were observed, the restorations were placed under field conditions in very young children by dental therapists and dental students. In the third study in China, where higher survival rates were reported, an experienced dentist placed the restorations in older children. It is likely that the differences were largely due to operator performance. In Syria, an operator effect was observed among the eight dentists who placed the ART restorations. Thus, it seems that when experienced operators place single-surface ART restorations in primary teeth, the survival rates approach those seen for ART restorations in permanent teeth. While ART has the potential to be particularly useful in providing care for the young child, the results of studies thus far need to be confirmed by other investigations.
ART related sealants
The success of sealants must be considered in two ways. While retention rate has routinely been used as a criterion for success, the ultimate success of a sealant should be expressed in terms of its ability to prevent caries, which is the primary purpose of sealants. Thus, biological outcomes should take precedence over mechanical outcomes.
Sealing surfaces with glass ionomer as part of the ART approach seems to be beneficial. In Zimbabwe, after three years, comparable surfaces that were not sealed had a four times higher chance of developing a dentinal lesion than those that were sealed. Despite the somewhat lower retention rate obtained with glass ionomer compared to composite resin sealants, its caries- preventive effect is still very acceptable. In the studies in Zimbabwe and China, caries progressed in 2 to 4 percent of the surfaces that had been sealed after three years and then only in those teeth that had lost the sealant.
More recent studies of ART sealants have used both improved materials and methods of placement and careful selection of surfaces in high-risk individuals with early enamel lesions and with deep fissures. The three-year survival of 71-72 percent for partially and fully retained glass ionomer sealants is extremely encouraging considering they were placed under field conditions.
The acceptability of ART
Discomfort during treatment
In Pakistan, patient discomfort was compared for restorations placed using ART with those placed using conventional procedures, i.e. rotary drill and amalgam, in patients aged 6-16 years. Discomfort was reported in fewer restorations placed with ART (19%) than in those placed using the drill and amalgam (36%). Similarly, in Indonesian children, discomfort as assessed using both physiological and behavioral methods, was less with the ART approach than with conventional procedures. In Chinese pre-school children, discomfort was experienced by only 7 percent of those receiving an ART restoration.
Post-operative sensitivity
In Zimbabwean teenagers, patients were asked about post-operative sensitivity two to four weeks after restoration placement. Post-operative sensitivity had been experienced in 6 percent of the ART restorations placed, but by the time of the evaluation, sensitivity had disappeared from all but one restoration. Similar results were reported in Chinese adolescents, with only 5 percent reported having some post-operative sensitivity.
Acceptance by patients
95 percent and 91 percent of secondary school students in Zimbabwe and China, respectively, expressed satisfaction with the ART procedure and with the resulting restoration(s). The same percentages of students reported that they would not hesitate to undergo the same treatment again if needed and would recommend it to their best friend.
ART in the health sector
In many countries there is already some provision for dental care in schools. This is often delivered through the use of mini-clinics or mobile dental units where traditional dental care is provided. The advantage of the use of ART in a mobile setting has been shown in South Africa.
For years a well-equipped mobile dental unit with three dental chairs was in operation in rural primary schools. However, it was reported that staff members had difficulties in treating these children because many of them were afraid of the dental treatment delivered through this system. It was decided to introduce ART into the care delivery system. A year after the introduction of ART, the percentage of extractions was reduced by 17 percent for permanent teeth and by 36 percent for primary posterior teeth compared to the year prior to ART. In addition, the percentage of amalgam restorations was reduced by 16 percent in permanent teeth and 1 percent in primary teeth. Conversely, restorative care increased by 33 percent in permanent teeth and 37 percent in primary posterior teeth. This positive change was ascribed to the patient-friendly nature of ART. It had reduced fear, mainly because of the absence of injections, and consequently had increased children's acceptance of restorative care. Another advantage was the simplified cross-infection control, particularly in an area with a high incidence of people with HIV and hepatitis.
Cost of ART restoration and ART sealant
The implementation phase of a cost-effectiveness study, comparing ART restorations using glass ionomer with amalgam restorations, started in Ecuador, Panama and Uruguay in May 2002. It will take more than three years before the results are published. Less complete data come from the ART study in Zimbabwe. When the cost of all consumable materials, such as filling material, gauze, cotton wool, mouth masks, gloves etc., was taken into account, it was estimated that an ART restoration or ART sealant cost US$ 0.47 in 1993 and US$ 0.51 in 1996, excluding personnel salaries. These estimates are much lower than recently published estimates for traditional amalgam restorations in non-EME countries. A BPOC demonstration project will include costing of the package.
Conclusion
• A large proportion of dentine lesions can be treated using the ART approach.
• The placement of restorations using the ART approach seems to cause less discomfort than conventionally placed amalgams.
• The survival rate of single-surface ART restorations using glass ionomers in the permanent dentition is higher in more recent studies compared to earlier studies.
• The average annual failure rate for ART restorations using glass ionomers in single-surfaces in the permanent dentition is about 4-5 percent for the first three years.
• The short-term survival of single-surface ART restorations using glass ionomers in the permanent dentition is comparable to amalgam restorations using conventional methods.
• The three-year survival of 71-72 percent for partially and fully retained glass ionomer sealants is extremely encouraging considering they were placed under field conditions.
• Caries meelopend in 2 to 4 percent of the surfaces that had been sealed after three years.
• To ensure optimal results from the ART approach, educational courses for operators new to the techniques need to be organized prior to applying the approach in the field and clinic.
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