The Dental Public Health Centre

Atraumatic Restorative Treatment:

Effectiveness, Technique

Author:

Steven K. Patterson, BSc, DDS, MPH

Dental Public Health Centre
University of Alberta
November, 2002
 Discussion Paper on Atraumatic
Restorative Treatment

November, 2002
Steven K. Patterson, BSc, DDS, MPH, Regional Dental Officer

Preamble

For many young children with advanced dental caries and limited access to definitive dental care
or who experience significant barriers of fear, there exists a need to provide restorative services
that allow for initial control of the disease. The Atraumatic Restorative Treatment (ART) has
been used in many parts of the world for this purpose.

Purpose of ART

The Medical Model of Caries Management proposes that to truly treat dental caries, more needs
to be done than simply treat the symptoms of disease by restoring frank, cavitated lesions in
teeth. Consideration must be given to eradicating or limiting the underlying infection that is
causing the disease in the first place. Essential to this model is the need to reduce the numbers of
bacteria in the mouth or preventive measures may not be sufficient to control the disease. ART
fits into this model as a means to reduce the significant numbers of bacteria often found in open,
cavitated lesions and prevent progression of the lesion, thus maintaining tooth structure,
occlusion. This is accomplished in a means that allows for easier treatment in more remote
locations where typical restorative dental services do not exist and in a painless way that does not
create a hardship for follow-up care.

The ART technique is a caries management technique used primarily in infants and preschool
children. It is based on excavation of primarily single surface caries lesions using hand
instruments and no anaesthesia, followed by an adhesive, glass ionomer (GI) restoration. The
adhesive nature of GI restorations allows for a minimal intervention restorative approach. Other
desirable properties of GI materials are fluoride-release, secondary caries inhibition and ability to
remineralize. (Cole 2000)

Although designed for developing nations where conventional dental care is often not available,
ART has a place in modern dental practice. (Cole 2000) It is part of a caries stabilization
approach and can be used with nervous patients or patients with medical or physical disability or
small children. It is especially useful for caries control when providing dental care in field
conditions that are not optimal or where conventional dental equipment is not available. ART has
been highly accepted by children and has resulted in retention of many teeth that otherwise
would have been extracted. (Smales 2000)
 Effectiveness of ART

Advantages of ART (Cole 2000)

No threatening dental equipment

Technique is biologically friendly and conserves sound tooth structure
Readily available using inexpensive hand instruments which can be taken to everyone
It does not involve the use of anaesthesia
Exploits beneficial properties of GI cements (adhesion, fluoride release, remineralization,
inhibition of secondary caries)
Ease of repair of restorations if necessary
Offers treatment and pain relief to individuals who would not necessarily receive
restorative dental care
Involves simple but effective infection control policy

Disadvantages of ART (Cole 2000)

Best suited for one-surface restorations

Inadequate physical properties of GI cements may influence long-term survival
Hand mixing may result in alterations of powder/liquid ratios and weaker restorations
Average time for a proper restoration may be 20 minutes. Potential hand fatigue.
Non-acceptance of technique by oral health care workers
Relative ease may result in inadequate removal of caries by inexperienced operators,
need for training

Smales et al (2002) reviewed studies showing permanent teeth retention of ART

restorations of 90% for Class I and V restorations.
Motsei et al. (2001) demonstrated 12 month retention results of ART in primary teeth of
57% and 84% in the permanent dentition. 72% of primary and 92% of permanent teeth
with ART restorations showed no caries after 1 year.
Smales et al. (2000) reviewed literature on ART used in primary teeth and reported Class
I & V single surface restorations have better success rates after 12 months of
approximately 80-95%. Class II restorations have lower success rates of approximately
55-75%.
Holmgren et al. (2000) showed 3 year results in Chinese schoolchildren of 92% for small
class I restorations and 77% for large class I restorations.
Cole et al. (2000) reviewed 3 year survival rates of one-surface ART restorations of 77-
88% which compares favourably with amalgam.
Frencken et al. (1999) supported the use of ART as a caries treatment modality that
benefits people based on the literature review. Newer materials have shown better 3 year
survival rates than initial studies.
Van Amerongen et al. (1999) indicated that the ART technique was reported as causing
less discomfort thatn conventional restorative procedures and preparations were smaller
in size.
 Anusavice (1999) writes that ART retention results for primary teeth are not as
impressive. GI materials meet some of the criteria for an ideal direct filling ART material
but may be deficient in ability to seal marginal gaps.
Luo et al. (1999) identified success rates of ART in primary teeth as 97% for ChemFlex
and 90% for Fuji IX in Class I preparations and 46% and 62% for permanent teeth after
12 months.
Mjor et al. (1999) recommends use of ART on high risk patients with rampant caries to
ascertain maximum benefit of the treatment.
Frencken et al. (1998) demonstrated experienced operators placed better ART restorations
than did inexperienced operators. ART provides high quality preventive and restorative
dental care.
Mallow et al. (1998) identified 92% of caries lesions required class I or class V
restorations and 85% were in lower molars. At 1 and 3 years, 86% and 80% were still
present with 76% and 58% being judged as successful.
Frencken et al. (1998) evaluated one surface ART restorations after three years and found
survival percentage of 85%. Mean treatment time for a one-surface restoration was 22.1
minutes.
Phantumvanit et al. (1996) reported survival rates of ART restorations after 1, 2, and 3
years that were close to amalgam restoration results. No differences were noted between
adults and children or between those placed by dentists or dental nurses.
Frencken et al. (1996) proposes the ART technique as making restorative care more
available to a larger part of the world, especially as it does not require equipment that
runs on electricity.

ART Technique

1) Recommended technique for providing ART:

a. Patient positioning
i. Comfortable position for both operator and patient should be adopted
(could be prone on bed/couch/portable dental chair or propped in suitable
sitting position)
ii. Adequate light source required

b. Identification of lesions
i. Recommend selection of single surface cavities, particularly on occlusal
surfaces of primary molars or buccal/lingual surfaces of primary teeth
ii. If considering permanent teeth then the procedure should be considered as
temporary or for emergency relief only

c. Isolation
i. Keep the environment as dry as possible using cotton rolls, dry angles or
gauze
ii. Remove debris and plaque from the tooth surface with cotton gauze or wet
cotton pellet
 d. Prepare the cavity
i. Widen entrance to lesion by removing unsupported enamel with hand
instruments, by placing excavator in entrance of lesion and rotating.
ii. Remove all soft carious tissues with excavator, removing caries first at the
DEJ in circular motions, before proceeding to cavity floor.
iii. The patient should be comfortable and the procedure should be painless
and quick (matter of seconds)
iv. Wash preparation with wet cotton pellets and then dry with cotton pellets,
trying not to over-dessicate the tooth

e. Placement of the restoration

i. Conditioner
1. The GI kit comes with a conditioner and the preparation should be
rubbed with conditioner on a cotton pellet for 15-20 seconds
2. Wash out the conditioner with at least three applications of a wet
cotton pellet, followed by gentle drying with a dry cotton pellet

ii. Mixing
1. Follow instructions of GI kit to mix or triturate capsules of cement
iii. Placement
1. Use a plastic carrying instrument to place the GI into the
preparation avoiding incorporation of bubbles. Condense the
material in place. It is best to slightly overfill the lesion and should
be accomplished while the material still has a glossy surface.
2. As it loses the glossy surface, further compression with a finger
will assist in placing the material
3. Use plastic Mylar strips for ensuring that the material does not
bond to the adjacent tooth

f. Finishing
i. After initial set (check time on GI kit) excess material may be removed
and check occlusion, removing more if required
ii. Apply a single coat of varnish with a cotton pellet or brush over the
surface of the restoration and keep dry for at least 30 seconds
iii. Instruct the patient not to eat for about an hour after appointment

2) Supplies required:
Gloves, mask
Mouth mirror Cotton rolls, 2x2 gauze, dry angles
Explorer Cotton pellets
Cotton pliers Mylar strips
Spoon Excavators GI cement (with conditioner and
Plastic filling instrument varnish)
Mixing slab (if powder/liquid kit) Clean water
Spatula (if mixing required)
 References

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FRENCKEN JE, MAKONI F, SITHOLE WD. ART restorations and glass ionomer sealants in Zimbabwe: survival
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