ART

ART or the Atraumatic Restorative Treatment is a method of caries management developed primarily for use in the Third World countries where skilled dental man power and facilities are limited and the population need is high. It is recognized by the World Health Organization. The technique uses simple hand instruments (such as chisels and excavators) to break through the enamel and remove as much caries as possible. When excavation of caries is complete (or as complete as can be achieved) the residual cavity is restored using a high-viscosity GIC. These GICs give increased strength under functional loads. A recent systematic review concluded that no difference exists in the survival of single-surface amalgam and ART restorations in both primary and permanent teeth (Mickenautsch et al, 2010).\

Interview: ‘ART has not been well received in dental schools’

by Daniel Zimmermann, DTI

Dental caries is considered one of the major public health problems in most developing countries. A simple restoration method developed in Africa in the 1980s based on glass-ionomers is often recommended when it comes to the treatment of widespread carious dentine. Dental Tribune Online spoke with Atraumatic Restorative Treatment founder Dr Prathip Phantumvanit from Thailand about the procedure and the manner in which it may help to overcome the dental caries epidemic.

DT Asia Pacific: Dr Prathip Phantumvanit, a new systematic review conducted in South Africa is supporting Atraumatic Restorative Treatment (ART) as an alternative to tooth restorations with amalgam. Have you read the report?

Dr Prathip Phantumvanit: This review confirms more or less the field tests on ART we have conducted in Thailand and other countries in recent years. When we compared the results with amalgam, we found that ART restorations were more successful than amalgam up to eight years of follow-up.

While amalgam is just a normal restoration, ART is a so-called “preventive restoration” owing to the fluoride released from the glass-ionomer restorative material used in the procedure. In addition, glass-ionomers are able to chemically seal and fuse with the tooth composition of both enamel and dentine. Amalgam cannot do that and, therefore, can easily cause micro-leakage. ART is also considered environmental friendly, whereas the mercury used in amalgam has been shown to be hazardous to both the environment and our health.

With this in mind, we believe that ART will be an alternative to amalgam restoration especially in the primary teeth, whose life span is less than ten years.

How commonly is the method used in countries like Thailand?

In Thailand, it is mainly used in primary health care and in rural settings where access to oral health services is limited. Here, three-year olds have an average of three carious teeth that need restoration and this number even increases further at the age of six. It is absolutely necessary to tackle the caries problem at village-based day-care centres with alternative practical approaches like ART. The simple caries removal without anaesthesia injection and no drilling make it more acceptable, especially for the treatment of young children.

What are the advantages and disadvantages of ART compared with other preventive measures such as water fluoridation?

Fluoride released from glass-ionomer restorative materials, which is directly active in the oral cavity in the area next to the tooth structure, as well as in the adjacent teeth, is very similar to any other prevention measures based on fluoride. Moreover, glass-ionomers on the tooth surface work as a fluoride reservoir in the oral cavity and are slowly released, as well as possibly recharged through the daily use of fluoride toothpaste. Another advantage of ART is the preventive restoration of the existing carious teeth to enhance the rehabilitation of the function of the teeth and to halt the progression of the caries in order to prevent pain and discomfort or even early extraction.

The only possible disadvantage I can think of is that dental health care personnel have to be involved in the procedure, which is slower, more expensive and time-consuming compared with mass public prevention measures such as water fluoridation.

Are there any factors inhibiting the implementation of ART in public oral health services in Asia?

Aside from paediatric dentists, community dentistry and public health departments, ART has not been well received in dental schools, especially in the field of operative dentistry. Some dental associations do not recognise ART as standard procedure for carious restoration and only recommend it for temporary or second-class restorations.

I believe that owing to its simplicity, with no need for rotary drilling instruments and other sophisticated dental equipment, many old-school dentists hesitate to accept ART as a correct approach to treating caries and I know that some colleagues even consider it a laborious and tiresome process. Others still associate glass-ionomers with lower strength and high wear in comparison with other restorative materials such as amalgam and composite resin.