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2/27/2016 1
ATRAUMATIC RESTORATIVE TREATMENT
2/27/2016 2
DEPARTMENT OF PUBLIC HEALTH
DENTISTRY
PREPARED BY:-
Dr. AMRITA RASTOGI
 History
 Introduction
 Definition
 Goals
 Principles of ART
 Indication and contraindications.
 Instruments and ma...
 Selection of Teeth with Carious &Cavities Suitable for ART
 Sharpening dental instrument.
 Hygiene and Control of Cros...
In many countries, the caries process frequently progresses
beyond the reversible stage and many people believe that loss
...
The World Health Organization actively promotes atraumatic
restorative treatment as a viable approach to meet the need for...
• Mid-1980s: Pioneered in Tanzania as part of a
community-based primary oral health program by the
University of Dar es Sa...
• 1988: WHO Collaborating Centre for Oral Health Services
Research at the University of Groningen, the Netherlands
develop...
 1992: At the 6th-month evaluation of the Thailand study in
1992, it became very apparent that the children who had been
...
 ART was developed by Dr. Jo Frencken DDS, MSc,
PhD, a dental researcher in the Netherlands.
 He was International Denti...
DEFINITION2
American Academy of Pediatric Dentistry
“a dental caries treatment procedure involving the
removal of soft, de...
2/27/2016 12
Avoiding
discomfort.
Reducing
infection
Preserving
the tooth
structure
Currently, ART is performed using glass-ionomer as
the restorative material.
2/27/2016 13
• The two main principles of ART...
The reasons for using hand instruments rather than electric rotating
hand pieces are: 8,9
- it makes restorative care acce...
The reasons for using glass-ionomer are:
- as the glass-ionomer sticks chemically to both enamel
and dentine, the need to ...
 In general ART is carried out only in the small and shallow
cavities (involving the dentine ) that are accessible to han...
 For the home-bound elderly and those living in nursing
homes.
 For mentally and/or physically handicapped patients.
 I...
2/27/2016 18
Contraindication
 There is presence of swelling (abscess) or fistula (opening
from abscess to the oral cavity)
 near the...
- there is an obvious carious cavity, but the opening is
inaccessible to hand instruments,
- there are clear signs of a ca...
2/27/2016 21
2/27/2016 22
MOUTH MIRROR
•Reflect light
•Indirect view
•Retract the cheek or
tongue
EXPLORER
•Identify the soft
carious d...
PAIR OF TWEEZERS
•Carry cotton wool,
rolls, pellets, wedges,
and articulating paper.
SPOON EXCATATOR
•Used for removing so...
DENTAL HATCHET
•Use for widening
the entrance to the
cavity.
APPLIER/CARVER
•Used for inserting
the mixed GIC
into cavity....
MIXING PAD AND
SPATULA
•Mixing GICc
OPERATING LIGHT
The light source can be
natural or artificial.
Artificial light : more...
2/27/2016 26
COTTON WOOL
ROLLS
•Use to absorb saliva
COTTON WOOL
PELLETS
•Use for cleaning
cavities.
2/27/2016 27
PETROLEUM JELLY
•Use to keep moisture
away from the GIC
•Prevent sticking of
gloves to the GIC
PLASTIC STRIP
...
2/27/2016 28
WEDGES •Use to hold the plastic
strips close
GIC
•Supplied as a powder
and liquid.
 Others are :
 Examination gloves
 Mouth mask
 Operation bed/ headrest extension stool
 Methylated alcohol
 Pressure...
1. ISOLATION
An important aspect for the success of ART is the control of
saliva around the tooth being treated. Cotton wo...
2. PREPARING THE CAVITY
 Remove plaque from the tooth surface
with a wet cotton wool pellet, and then
dry the surface wit...
 Excavation is easy to do when the tooth is dry. Therefore,
change saturated cotton wools for dry ones.
 Carious dentine...
In order to improve the chemical bonding of glass-ionomer
to the tooth structures, the cavity walls must be very clean.
It...
 The dentine conditioner is usually a 10% solution of
polyacrylic acid. Apply one drop of the conditioner on a
pad or the...
 The glass-ionomer liquid can be used for cleaning the
cavity if it contains the same acid as is used for
conditioning. U...
 Treatment Material
The material used for restoring cavities and sealing pits and
fissures is glass-ionomer. This materia...
 Clinical Characteristics
Glass-ionomer bonds chemically to enamel and dentine
and provides a good cavity seal.
- One of ...
-After 24 hours, when completely set, adverse reactions do
not occur anymore.
- Compared to established dental restorative...
 Mixing
 It is essential to closely follow the handling instructions of
the manufacturer particularly with respect to po...
2/27/2016 40
 First spread the liquid with the spatula over a surface of
about 1.5 cm2. Start mixing by adding one half of the
powder ...
 Insertion of the mixture into the prepared cavity and over
the remaining fissures must begin immediately. Use the
applie...
 Rub a small amount of petroleum jelly on the gloved index
finger and press the soft restorative material firmly into the...
 The excess material is removed with a
carver.
 Cover the ART restoration with a new
layer of petroleum jelly
 The pati...
 Dispense both powder and liquid onto the slab only when you have the
cavity properly dried and protected from saliva.
 ...
Anterior teeth step-by-step
1. Work in a dry environment using cotton wool rolls.
Replace these as required.
2. Clean the ...
5. Condition the cavity as described for the one-surface cavity.
6. Mix the glass-ionomer as described before and insert i...
8. Remove the strip and wedge, and cover the restoration
with petroleum jelly.
9. Remove any excess material with the carv...
 A breakage in the tooth surface or a cavity in the tooth is
recognized as decayed or carious tooth. With the probe
gentl...
 Just a change of the tooth surface does not necessarily
mean it is caries. Sometimes, teeth can be discoloured
because o...
Carious cavities are usually classified by the number of surfaces
affected. 10
 One-Surface Cavities: These occur in only...
a. Pits and fissures on occlusal
surfaces of premolars and
molar
b. Pits on lingual surfaces of
upper incisors
c. Buccal g...
Multiple-Surface Cavities
These affect two or more surfaces of a tooth, i.e.:
a. occlusal and proximal surfaces of premola...
a. Occlusal and proximal surfaces of a
premolar and a molar.
b. Occlusal and lingual surfaces
of a molar.
c. Proximal and ...
 Hand instruments used for cutting hard tooth
tissues, the excavator, dental hatchet and carver,
must be sharp to be effe...
Sharpening the Dental Hatchet and Carver
A special flat stone, for example an 'Arkansas' stone, is used
for sharpening the...
Instruments should be sterilized after they have been
sharpened.
2/27/2016 57
Correct and incorrect position of
dental hat...
Sharpening Spoon Excavator
 Place the round surface of the
excavator in the oil and make
small strokes from the center of...
 If available, always wear gloves. Cleaning and disinfection of the
working place and sterilization of instruments is ess...
 To avoid the risk of infection with diseases such as the
human immunodeficiency virus (HIV) and hepatitis B
virus (HBV),...
Operator’s position (Your
Position)
 Operator should sit firmly on the
stool, with a straight back, thighs
parallel to th...
2/27/2016 62
Oral care is best provided by a team consisting of an
operator and an assistant. However, assistance may not
...
Patient’s position
 The patient should lie on a flat surface that will provide
safe and secure body.
 support and a comf...
Patient’s head position
- Backward tilt lifting the chin for access to upper teeth.(a)
- Forward tilt dropping the chin fo...
 Range of positions : 10 to 1 on the clock.
 Most commonly used positions:
• direct rear position (12 o'clock) and
• rig...
• No restoration or sealant, irrespective of the material used, lasts
forever. Some restorations may last for many years, ...
Examine the tooth carefully for signs of caries.
 If the surface is hard, leave it alone.
 If the surface is carious, re...
A restoration may not be acceptable or unsatisfactory when
1. it is completely missing,
2. a large part of it has broken a...
 Use of easily available and relatively inexpensive hand
instrument rather than expensive electrically driven dental
equi...
 A straight forward and simple infection control practice
without the need to use sequentially autoclaved hand pieces.
 ...
 The restoration can be easily repaired if damaged.
 Low cost
 ART may be used to restore and prevent caries in young
p...
 Long-term survival rates for glass-ionomer ART restorations and
sealants are not available.
 Use limited to small- and ...
 Treating dental caries using the ART approach without
emphasis on preventive measures is a job only half done.
 Importa...
 The ART approach was pioneered in Tanzania in the mid 1980
which was followed by several community field trials
conducte...
Studies conducted in several countries showed high
survival rates of atraumatic restorative treatment one-
surface restora...
 In a meta-analysis of 5 ART effectiveness studies, the retention
of ART restorations were compared to those using a
conv...
 The 4 other studies found that the difference in survival in the
two techniques were not statistically different. The st...
 In clinical trials of ART compared to traditional treatment conducted
by the Pan American Health Organization (PAHO) in ...
 Survival rates of restorations using ART vary depending on
several factors.
 In a meta-analysis of studies reporting su...
 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...
 Survival rates differ greatly between studies, but rates are hard
to compare because the populations differ so greatly.
...
 Lo et al. report a six-year follow up of ART in China,
concluding that smaller ART restorations survive longer than
larg...
 The first report that described the use of the ART approach in a
public service system originated from South Africa. ART...
 The Mexican experience of incorporating ART into the public
service stands out as a good example . It started with an AR...
 According to nine chief dental officers of 10 Latin American
countries, ART has been introduced into their countries‘ pu...
 The experiences in South Africa, Mexico, Tanzania, the
Latin American countries and Cambodia show that the
proper implem...
 Strategies for successful incorporation of ART into public
oral health services should, therefore, include organisation
...
 Brazil 34
Atraumatic Restorative Treatment (ART) for a
disadvantaged Brazilian Community:
 “Training oral health person...
2/27/2016 89
 South Africa 36
 Introducing the Atraumatic Restorative
Treatment (ART) approach in South “Refugee
Services:
 In 1997,...
2/27/2016 91
 Sri Lanka 38
 Atraumatic Restorative Treatment (ART) Programme in Sri
Lanka:
 “Once a month a team of dentists and abo...
2/27/2016 93
 Turkey 39
 Atraumatic Restorative Treatment (ART)
Programme in some rural areas of Turkey:
“Dentists and often dental s...
2/27/2016 95
 Atraumatic Restorative Treatment (ART) is a minimally invasive
approach to both prevent dental carious lesions and stop ...
performed not only by dentists but also by other operating dental
personnel, such as dental therapists also it can be perf...
1. Jo E. FRENCKEN Evolution of the ART approach: highlights and achievements J
Appl Oral Sci. 2009; 17(sp. issue):78-83
2....
5. Naty Lopez, Sara SimpserRafalin , and Peter Berthold. Atraumatic
Restorative Treatment for Prevention and Treatment of ...
8. Palwasha Momand, Jayanthi Stjernswärd How to carry out Atraumatic
RestorativeTreatment (ART) on decayed teeth - A Train...
13. Roger J Smales, Hak-Kong Yip The atraumatic restorative treatment (ART)
approach for primary teeth: review of literatu...
18. Pilot T. Introduction – ART from a global perspective. Community Dent
Oral Epidemiol 1999;27:421-2.
19. Yip HK, Smales...
21. Kalf-Scholte, S.M., et al., Atraumatic restorative treatment (ART): a
three-year clinical study in Malawi--comparison ...
25. Rahimtoola, S. and E. van Amerongen, Comparison of two tooth-
saving preparation techniques for one-surface cavities. ...
30. Mallow, P.K., C.S. Durward, and M. Klaipo, Restoration of permanent
teeth in young rural children in Cambodia using th...
34. Mickenautsch, S, Yengopal V, Banerjee A. Atraumatic restorative
treatment versus amalgam restoration longevity: a syst...
2/27/2016 107
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atraumatic restorative treatment

  1. 1. 2/27/2016 1
  2. 2. ATRAUMATIC RESTORATIVE TREATMENT 2/27/2016 2 DEPARTMENT OF PUBLIC HEALTH DENTISTRY PREPARED BY:- Dr. AMRITA RASTOGI
  3. 3.  History  Introduction  Definition  Goals  Principles of ART  Indication and contraindications.  Instruments and materials used.  Principal steps involved.  Restoring multiple surface Cavities Using ART 2/27/2016 3
  4. 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 2/27/2016 4
  5. 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. 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. 2/27/2016 6
  7. 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. 2/27/2016 7
  8. 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. 2/27/2016 8
  9. 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 2/27/2016 9
  10. 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." 2/27/2016 10
  11. 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”. 2/27/2016 11
  12. 12. 2/27/2016 12 Avoiding discomfort. Reducing infection Preserving the tooth structure
  13. 13. Currently, ART is performed using glass-ionomer as the restorative material. 2/27/2016 13 • 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. 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. 2/27/2016 14
  15. 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. 2/27/2016 15
  16. 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. 2/27/2016 16
  17. 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. 2/27/2016 17
  18. 18. 2/27/2016 18
  19. 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. 2/27/2016 19
  20. 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. 2/27/2016 20
  21. 21. 2/27/2016 21
  22. 22. 2/27/2016 22 MOUTH MIRROR •Reflect light •Indirect view •Retract the cheek or tongue EXPLORER •Identify the soft carious dentine
  23. 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. 2/27/2016 23
  24. 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. 2/27/2016 24
  25. 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. 2/27/2016 25
  26. 26. 2/27/2016 26 COTTON WOOL ROLLS •Use to absorb saliva COTTON WOOL PELLETS •Use for cleaning cavities.
  27. 27. 2/27/2016 27 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
  28. 28. 2/27/2016 28 WEDGES •Use to hold the plastic strips close GIC •Supplied as a powder and liquid.
  29. 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 2/27/2016 29
  30. 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. 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. 2/27/2016 31
  32. 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. 2/27/2016 32 After all the caries is removed from the cavity, it is cleaned with wet cotton wool
  33. 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. 2/27/2016 33
  34. 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. 2/27/2016 34 Application of dentine conditioner
  35. 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. 2/27/2016 35 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. 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. 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. 2/27/2016 37
  38. 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. 2/27/2016 38
  39. 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. 40. 2/27/2016 40
  41. 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. 2/27/2016 41 The final mixture should look smooth like chewing gum.
  42. 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. 2/27/2016 42
  43. 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. 2/27/2016 43
  44. 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. 2/27/2016 44
  45. 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. 2/27/2016 45
  46. 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. 2/27/2016 46
  47. 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. 2/27/2016 47
  48. 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. 2/27/2016 48
  49. 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. 2/27/2016 49
  50. 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. 2/27/2016 50
  51. 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. 2/27/2016 51
  52. 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. 2/27/2016 52
  53. 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. 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. 2/27/2016 54
  55. 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. 2/27/2016 55 Sharpening Dental Instruments 10,11
  56. 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. 2/27/2016 56
  57. 57. Instruments should be sterilized after they have been sharpened. 2/27/2016 57 Correct and incorrect position of dental hatchet for sharpening. Instrument must be held parallel to the flat surface of the sharpening stone.
  58. 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. 2/27/2016 58
  59. 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. 2/27/2016 59
  60. 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. 2/27/2016 60
  61. 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. 2/27/2016 61
  62. 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. 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. 2/27/2016 63 Patient’s position
  64. 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) 2/27/2016 64
  65. 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) 2/27/2016 65
  66. 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. 2/27/2016 66
  67. 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. 2/27/2016 67
  68. 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. 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. 2/27/2016 69
  70. 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. 2/27/2016 70
  71. 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. 2/27/2016 71
  72. 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. 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. 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. 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. 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. 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 2/27/2016 77
  78. 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 2/27/2016 78
  79. 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. 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 2/27/2016 80
  81. 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 2/27/2016 81
  82. 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. 2/27/2016 82
  83. 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. 2/27/2016 83
  84. 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 2/27/2016 84
  85. 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 2/27/2016 85
  86. 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 2/27/2016 86
  87. 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. 2/27/2016 87
  88. 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.” 2/27/2016 88
  89. 89. 2/27/2016 89
  90. 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”. 2/27/2016 90
  91. 91. 2/27/2016 91
  92. 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”. 2/27/2016 92
  93. 93. 2/27/2016 93
  94. 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”. 2/27/2016 94
  95. 95. 2/27/2016 95
  96. 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, 2/27/2016 96
  97. 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. 2/27/2016 97
  98. 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. 2/27/2016 98
  99. 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  2/27/2016 99
  100. 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. 2/27/2016 100
  101. 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. 15. Mjor IA, Gordon VV-A review of atraumatic restorative treatment (ART), Int Dent J: 1999 Jun;49(3):127-31. 16. Smales RJ. Yip HK. The atraumatic restorative treatment (ART) approach for the management of dental caries. Quintessence Int 2002;33:427-32. 17. Atraumatic Restorative Treatment (ART): Recent Development and Application. J Pub Health Dent 1999, 43(2): 32-9. 2/27/2016 101
  102. 102. 18. Pilot T. Introduction – ART from a global perspective. Community Dent Oral Epidemiol 1999;27:421-2. 19. Yip HK, Smales RJ. Glass ionomer cements used as fissure sealants with the atraumatic restorative treatment (ART) approach: review of literature. Int Dent J 2002;52:67-70 19. Kemoli, A.M. and W.E. van Amerongen, Influence of the cavity-size on the survival rate of proximal ART restorations in primary molars. Int J Paediatr Dent, 2009. 19(6): p. 423-30. 20. Frencken, J.E., et al., Effectiveness of Single-surface ART Restorations in the Permanent Dentition: A Meta-analysis. Journal of Dental Research, 2004. 83(2): p. 120-123. 2/27/2016 102
  103. 103. 21. Kalf-Scholte, S.M., et al., Atraumatic restorative treatment (ART): a three-year clinical study in Malawi--comparison of conventional amalgam anARTrestorations. D J Public Health Dent, 2003. 63(2): p. 99-103. 22. Phantumvanit, P., et al., Atraumatic restorative treatment (ART): a three-year community field trial in Thailand--survival of one-surface restorations in the permanent dentition. J Public Health Dent, 1996. 56(3 Spec No): p. 141-5; discussion 161-3. 23. Taifour, D., et al., Comparison between restorations in the permanent dentition produced by hand and rotary instrumentation--survival after 3 years. Community Dent Oral Epidemiol, 2003. 31(2): p. 122-8. 24. Mandari, G.J. and M.I. Matee, Atraumatic Restorative Treatment (ART): theTanzanian experience. Int Dent J, 2006. 56(2): p. 71-6. 2/27/2016 103
  104. 104. 25. Rahimtoola, S. and E. van Amerongen, Comparison of two tooth- saving preparation techniques for one-surface cavities. ASDC J Dent Child, 2002. 69(1): p. 16-26, 11. 26. PAHO: Oral health of low income children. Procedures for Atraumatic Restorative Treatment. In Final Report Pan American Health Organization, Washington DC;2006 27. Steele, J., ART for treating root caries in older people. Evid Based Dent, 2007.8(2): p. 51. 28. van 't Hof, M.A., et al., The atraumatic restorative treatment (ART) approach formanaging dental caries: a meta-analysis. Int Dent J, 2006. 56(6): p. 345-51. 29. Kemoli, A.M. and W.E. van Amerongen, Influence of the cavity-size on the survival rate of proximal ART restorations in primary molars. Int J Paediatr Dent, 2009. 19(6): p. 423-30. 2/27/2016 104
  105. 105. 30. Mallow, P.K., C.S. Durward, and M. Klaipo, Restoration of permanent teeth in young rural children in Cambodia using the atraumatic restorative treatment (ART) technique and Fuji II glass ionomer cement. Int J Paediatr Dent, 1998.8(1): p. 35-40. 31. Lopez, N., S. Simpser-Rafalin, and P. Berthold, Atraumatic restorative treatment for prevention and treatment of caries in an underserved community. Am J Public Health, 2005. 95(8): p. 1338-9. 32. Chalmers, J.M., Minimal intervention dentistry: part 2 Strategies for addressingrestorative challenges in older patients. J Can Dent Assoc, 2006. 72(5): p. 435-40. 33. Mickenautsch, S., I. Munshi, and E.S. Grossman, Comparative cost of ART andconventional treatment within a dental school clinic. SADJ, 2002. 57(2): p. 52-8. 2/27/2016 105
  106. 106. 34. Mickenautsch, S, Yengopal V, Banerjee A. Atraumatic restorative treatment versus amalgam restoration longevity: a systematic review. Clin Oral Investig 2010; 14:233-40. 34. Lo EC, Holmgren CJ, Hu D, van Palenstein Helderman W. Six-year follow up atraumatic restorative treatment restorations placed in Chinese school children.Community Dent Oral Epidemiol 2007; 35:387-92 35.http://www.whocollab.od.mah.se/amro/brazil/data/brazilart.html. 36. http://www.whocollab.od.mah.se/expl/artsa.html 37.(http://www.whocollab.od.mah.se/searo/srilanka/data/srilankaart.ht ml) 38. (http://www.whocollab.od.mah.se/euro/turkey/data/turkeyart.html) 2/27/2016 106
  107. 107. 2/27/2016 107

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