seminar on atraumatic restorative treatment

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2. ATRAUMATIC RESTORATIVE TREATMENT
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DEPARTMENT OF PUBLIC HEALTH
DENTISTRY
PREPARED BY:-
Dr. AMRITA RASTOGI

3.  History
 Introduction
 Definition
 Goals
 Principles of ART
 Indication and contraindications.
 Instruments and materials used.
 Principal steps involved.
 Restoring multiple surface Cavities Using ART
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4.  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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5. 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.2/27/2016 5

6. 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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7. • 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.
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8. • 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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9.  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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10.  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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11. 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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12. 2/27/2016 12
Avoiding
discomfort.
Reducing
infection
Preserving
the tooth
structure

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

14. 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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15. 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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16.  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.
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17.  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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18. 2/27/2016 18

19. 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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20. - 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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21. 2/27/2016 21

22. 2/27/2016 22
MOUTH MIRROR
•Reflect light
•Indirect view
•Retract the cheek or
tongue
EXPLORER
•Identify the soft
carious dentine

23. 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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24. 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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25. 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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26. 2/27/2016 26
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.

29.  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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30. 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.
2/27/2016 30For teeth in the lower jaw For teeth in the upper jaw

31. 2. PREPARING THE CAVITY
 Remove 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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32.  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.
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After all the caries is removed from the cavity, it is cleaned
with wet cotton wool

33. 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.
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34.  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.
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Application of
dentine conditioner

35.  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.
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It is advisable to dispense one drop for
conditioning and a second drop for
mixing,
keeping the bottle in the vertical
position between dispensing.

36.  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
Composition
 The 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. 2/27/2016 36

37.  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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38. -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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39.  Mixing
 It 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 and2/27/2016 39

40. 2/27/2016 40

41.  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.
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The final mixture should
look smooth like chewing
gum.

42.  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.
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43.  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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44.  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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45.  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.
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46. 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.
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47. 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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48. 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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49.  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.
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50.  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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51. 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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52. a. Pits and fissures on occlusal
surfaces of premolars and
molar
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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53. 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.
2/27/2016 53

54. a. Occlusal and proximal surfaces of a
premolar and a molar.
b. Occlusal and lingual surfaces
of a molar.
c. Proximal and buccal surfaces
of an anterior tooth.
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55.  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.
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Sharpening Dental Instruments 10,11

56. 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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57. Instruments should be sterilized after they have been
sharpened.
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Correct and incorrect position of
dental hatchet for sharpening.
Instrument must be held parallel
to the flat surface of the
sharpening stone.

58. 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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59.  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.
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60.  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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61. 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.
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62. 2/27/2016 62
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

63. Patient’s position
 The 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.
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Patient’s position

64. 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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65.  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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66. • 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.
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67. 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.
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68. A restoration may not be acceptable or unsatisfactory when
1. 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.
2/27/2016 68
Whatever the reason, clean the cavity
completely, apply dentine conditioner and refill
the cavity according to the description .

69.  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.
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70.  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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71.  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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72.  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.
2/27/2016 72

73.  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
2/27/2016 73

74.  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.
2/27/2016 74

75. 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.2/27/2016 75

76.  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
2/27/2016 76

77.  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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78.  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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79.  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.
2/27/2016 79

80.  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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81.  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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82.  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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83.  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.
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84.  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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85.  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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86.  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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87.  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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88.  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.”
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89. 2/27/2016 89

90.  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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91. 2/27/2016 91

92.  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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93. 2/27/2016 93

94.  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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95. 2/27/2016 95

96.  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,
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97. 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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98. 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.
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99. 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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100. 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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101. 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.
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J: 1999 Jun;49(3):127-31.
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102. 18. Pilot T. Introduction – ART from a global perspective. Community Dent
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19. Yip HK, Smales RJ. Glass ionomer cements used as fissure sealants with
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19. Kemoli, A.M. and W.E. van Amerongen, Influence of the cavity-size on
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