Frencken JE. The state-of-the-art of ART sealants. Dent Update. 2014; 41:119-124
Frencken JE, van Amerongen WE. The atraumatic restorative treatment approach. In: Fejerskov O, Kidd E (eds). Oxford: Blackwell Munksgaard Ltd; 2008
Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, Eden E. Minimal Intervention Dentistry (MID) for managing dental caries – a review. Int Dent J. 2012; 62:223-243
Schmaltz G. ART – a method on its way into dentistry. Clin Oral Invest. 2012; 16:1335-1336
Leal SC, De Menezes Abreu DM, Frencken JE. Dental anxiety and pain related to Atraumatic Restorative Treatment. J Appl Oral Sci. 2009; 17:84-88
Frencken JE, Leal SC, Navarro MFL. 25 years atraumatic restorative treatment (ART) approach: a comprehensive overview. Clin Oral Invest. 2012; 16:1337-1346
Estupiñán-Day S, Tellez M, Kaur S, Milner T, Solari A. Managing dental caries with atraumatic restorative treatment in children: successful experience in three Latin American countries. Rev Panam Salud Publica. 2013; 33:237-243
Davies GN. Early childhood caries – a synopsis. Community Dent Oral Epidemiol. 1998; 26:106-116
Kateeb ET, Warren JJ, Damiano P, Momany E, Kanellis M, Weber-Gasparoni K, Ansley T. Teaching atraumatic restorative treatment in US dental schools: a survey of predoctoral pediatric dentistry program directors. J Dent Educ. 2013; 77:1306-1314
da Mata C, Allen PF, Cronin M, O'Mahony D, McKenna G, Woods N. Cost-effectiveness of ART restorations in elderly adults: a randomized clinical trial. Community Dent Oral Epidemiol. 2013; https://doi.org/10.1111/cdoe.12066
Molina GF, Leal SC, Frencken JE. Strategies for managing carious lesions in patients with disabilities – a systematic review. J Disabil Oral Health. 2011; 12:159-167
Holmgren CJ, Figueredo MC. Two decades of ART: improving on success through further research. J Appl Oral Sci. 2009; 17:122-134
Modena KC, Casas-Apayco LC, Atta MT, Costa CA, Hebling J, Sipert CR, Navarro MF, Santos CF. Cytotoxicity and biocompatibility of direct and indirect pulp capping materials. J Appl Oral Sci. 2009; 17:544-554
Mickenautsch S. How well are GIC product labels related to current systematic review evidence?. Dent Update. 2011; 38:634-644
De Amorim RG, Leal SC, Frencken JE. Survival of ART Sealants and ART restorations: a meta-analysis. Clin Oral Invest. 2012; 16:429-441
Van't Hof MA, Frencken JE, van Palenstein Helderman WH, Holmgren CJ. The atraumatic restorative treatment (ART) approach for managing dental caries: a meta-analysis. Int Dent J. 2006; 56:345-351
Farag A, van der Sanden WJ, Abdelwahab H, Frencken JE. Survival of ART restorations assessed using selected FDI and modified ART restoration criteria. Clin Oral Invest. 2011; 15:409-415
Lo ECM, Holmgren CJ, Hu D, Wan H, van Palenstein Helderman W. Six-year follow-up of atraumatic restorative treatment restorations placed in Chinese school children. Community Dent Oral Epidemiol. 2007; 35:387-392
Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Invest. 2011; 15:265-271
Mickenautsch S, Yengopal V, Banerjee A. Atraumatic restorative treatment versus amalgam restoration longevity: a systematic review. Clin Oral Invest. 2010; 14:233-240
Mickenautsch S, Yengopal V. Failure rate of atraumatic restorative treatment using high-viscosity glass-ionomer cement compared to that of conventional amalgam restorative treatment in primary and permanent teeth: a systematic review update. J Minim Interv Dent. 2012; 5:63-124
Raggio DP, Hesse D, Lenzi TL, AB Guglielmi C, Braga MM. Is atraumatic restorative treatment an option for restoring occlusoproximal caries lesions in primary teeth? A systematic review and meta-analysis. Int J Paediatr Dent. 2012; https://doi.org/10.1111/23
de Amorim RG, Leal SC, Mulder J, Creugers NHJ, Frencken JE. Amalgam and ART restorations in children: a controlled clinical trial. Clin Oral Invest. 2014; 18:(1)117-124
Frencken JE, van't Hof MA, van Amerongen WE, Holmgren CJ. Effectiveness of single-surface ART restorations in the permanent dentition: a meta-analysis. J Dent Res. 2004; 83:120-123
Taifour D, Frencken JE, Beiruti N, Van't Hof MA, Truin GJ. Effectiveness of glass-ionomer (ART) and amalgam restorations in the deciduous dentition – results after 3 years. Caries Res. 2002; 36:437-444
Farag A, van der Sanden WJM, Abdelwahab H, Mulder J, Frencken JE. 5-Year survival of ART restorations with and without cavity disinfection. J Dent. 2009; 37:468-474
Mickenautsch S, Yengopal V. Absence of carious lesions at margins of glass-ionomer cement and amalgam restorations: an update of systematic review evidence. BMC Res Notes. 2011; 11:(4)
ART is less anxiety-and pain-provoking than traditional restorative treatments; administration of local anaesthesia is rarely required. Systematic reviews have provided evidence of the high level of effectiveness of high-viscosity glass-ionomer ART restoration in restoring single-surface cavities, both in primary and permanent posterior teeth, but its survival rates in restoring multiple-surface cavities in primary posterior teeth needs to be improved. Insufficient information is available regarding the survival rates of multiple-surface ART restorations in permanent teeth. Evidence from these reviews indicates no difference in the survival rates of single-surface high-viscosity glass-ionomer ART restorations and amalgam restorations in primary and permanent posterior teeth.
Clinical Relevance: Where indicated, high-viscosity glass-ionomer ART restorations can be used alongside traditional restorations. ART provides a much more acceptable introduction to dental restorative care than the traditional ‘injection, drill and fill’.
Article
This article is the second one about the Atraumatic Restorative Treatment (ART) approach and covers the effectiveness of ART restorations. The first described the effectiveness of ART sealants.1 An ART restoration involves removal of the decomposed carious tooth tissues with a sharp metal excavator. This procedure is relatively easily performed in medium-sized and large cavities. In small cavities, hand instruments, like the enamel access cutter and the chisel, are used to widen the cavity opening further to facilitate entrance to it with the excavator. The cleaned cavity is then restored with an adhesive dental material, mostly a high-viscosity glass-ionomer, which simultaneously seals any remaining pits and fissures that remain at risk.2 In other words, the use of the drill removes too much healthy and/or remineralizable The protocol for application of an ART restoration is presented in Table 1 and illustrated in Figure 1.
Figure 1. ART restoration step-by-step using a high-viscosity glass-ionomer (Ketac Molar Easymix). Dentine carious cavity in tooth LLE. (a) Notice the discoloration around the cavity opening. It indicates that the carious lesion has extended under the enamel. This unsupported enamel is demineralized and will break off easily under slight pressure. (b) Opening of cavity further for access with the Enamel Access Cutter (ART instrument). (c) Carious tissue removal using a small and sharp excavator. (d) The conditioner is applied to the cleaned cavity and pits and fissures with a cotton wool pellet. (e) Carefully dried cavity before placing the high-viscosity glass-ionomer. (f) Firm finger pressure has been applied over the occlusal surface and excess filling material has been removed with a carver instrument. The ART restoration presented after the bite has been adjusted showing the sealant restoration: the cavity is restored and the pits and fissures are sealed.
Isolate the tooth with cotton wool rolls. Keep the treatment area free from saliva.
With an explorer, gently remove plaque and food debris from the deepest parts of the available pits and fissures.
Wash the pits and fissures, using wet cotton wool pellets.
Assess the extent of the carious lesion.
Enlarge the entrance of the cavity if it is found to be too small, using an Enamel Access Cutter or dental hatchet.
Break only very thin enamel that might fracture when the restoration is in place, using a hatchet.
Remove the carious dentine with hand excavators in a scooping movement, starting at the dentine-enamel junction and ending at the floor of the cavity. Leaving a little decomposed dentine behind is permitted if it is difficult to remove or if the child becomes impatient.
Clean the cavity with a wet cotton pellet(s) followed by a dry one.
Ensure that the fissures which run into the cavity are free from debris. Remove debris with a sharp probe.
Ensure that the enamel that forms the cavity opening is free from demineralization (as far as possible).
Place 2 drops of liquid on the mixing pad. The first one, positioned in the corner of the pad, usually contains air bubbles and is, therefore, used for conditioning. Without releasing pressure, move the bottle to the centre of the pad and place a second drop there. This one should not contain air bubbles and will be used for mixing.
Condition the cavity and adjacent pits and fissures with diluted (15–20%) polyacrylic acid by passing a moist cotton pellet, dipped in the conditioner, around the dentine and enamel in the cavity for some 10–15 seconds. Bottled dentine conditioner is also availabe.
Ensure that the pellet touches the cavity walls. This is not always easy in small cavities. Use pellets appropriate to the size of the cavity. A disposable brush can also be used.
Wash with a wet cotton pellet(s) for some 5 seconds. Repeating this is necessary.
Dry with cotton pellet(s) (do not use the air syringe). The cavity will look shiny. Keep this situation uncontaminated by saliva and/or blood.
Mix the GIC according to the manufacturer's instructions. Only accept a properly mixed GIC; no runny or dry mixture is acceptable. Encapsulated GIC can also be used.
Insert the GIC material into the cavity with the applier/carver instrument. Push the GIC into the corner(s) of the cavity (in case of an enamel overhang) with the round end of the medium excavator. Insert a second portion of GIC and press it into place with the round end of the large excavator. Fill the adjacent pits and fissures but DO NOT overfill much, as the excess has to be removed.
Rub some petroleum jelly over your index finger (very thin layer), place the finger over the tooth surface and press for 20 seconds.
Remove the visible GIC excess with the carver end of the applier/carver instrument.
Check the occlusion with articulation paper.
Wait until the material has set a bit and then adjust the bite with a medium-sized excavator and/or carver instrument.
Remove petroleum jelly-covered top layer of the GIC with a large excavator and/or carver instrument. Ensure a smooth GIC-onto-enamel junction. Use the round end of the small and/or large excavator to achieve this.
Protect the restoration with a thin layer of petroleum jelly again.
Remove the cotton wool rolls.
Ask the patient not to eat for at least one hour.
The 2012 review of Minimal Intervention Dentistry (MID) for managing dental caries, documented by the FDI task group, presented principle guidelines for treating dentine cavities.3 These are:
Removing decomposed (previously labelled ‘infected’) dentine, because it is useless;
Leaving demineralized (previously named ‘affected’) dentine behind, because it can remineralize; and
Restoring the cleaned cavity with a biocompatible material that has optimum physical properties, because it will ensure long-term integrity of the restored tooth. The review shows that removal of decomposed dentine is most adequately achieved through the use of a chemo-mechanical gel, but this method takes a relatively long time. The next most effective method is using a sharp metal hand excavator. The rotating metal dental drill has a tendency to over-prepare the cavity.1 enamel and dentine. The dental material used to restore the cleaned cavity should be able to adhere to enamel and dentine properly for a long time without serious side-effects on the tooth and other oral tissues.
ART restorations in oral healthcare
The indication for using ART was initially restricted to the treatment of cavitated teeth that would otherwise have been extracted in people from communities in developing countries. Its success in saving such teeth, through quality restorations, led to the question as to whether ART could be a beneficial treatment in oral healthcare systems operating in developed countries.4 It is less anxiety-and pain-provoking than the traditional restorative treatments and, consequently, administration of local anaesthesia is usually not required if the ART protocol is carried out correctly.5 Attending an ART training course would benefit the dental practitioner in producing quality ART restorations in both primary and permanent dentitions. ART restorations using high-viscosity glass-ionomer have been proven to be suitable for use in children, not only in the very young but also in school children. ART restorations have been better accepted by children than the traditional restorative treatment.6 They are also more cost-effective than conventional treatment.7 Davies, in 1998, already predicted that ART would provide a much more acceptable introduction to dental care than ‘injection, drill and fill’.8 It is most probably one of the reasons why dental professionals in countries as far apart as Brazil, Japan, the Netherlands, South Africa, Turkey, the UK and the USA use ART to treat children in private practice,6 and why a plea was made to facilitate the incorporation of the ART approach in the curricula of US dental schools.9
The use of the ART in adults has not been well documented, with most studies having been carried out on posterior teeth and a few on anterior ones.6 Neither the extent to which the ART procedure is beneficial to adult patients and dental practitioners, nor its appropriateness for use on the elderly, is therefore known. It is conceivable that ART, presenting a care treatment that is mobile, and not requiring a dental surgery, would be a valuable asset in a (medical) oral care package for dentate elderly people living in institutions and those who are housebound. As little research has been conducted to assess its suitability in those circumstances, studies on this aspect should receive high priority amongst dental professionals and (oral) healthcare providers. Compared to conventional restorative treatment, placing restorations in elderly adults using ART is more cost-effective after one year.10 The ART approach has also been suggested to be a viable option for treating people with disabilities.11 Again, this possible indication for the use of ART in oral healthcare services has so far received little attention. Those who are interested in investigating aspects of ART will find the comprehensive list of research topics compiled by Holmgren and Figueredo12 useful. Specific indications for treating dentine cavities through the use of the ART protocol are provided in the sections below.
How effective are ART restorations?
Materials used with ART
In early 1990, when the definition of the ART approach was under debate, it was emphasized that the material to be used in conjunction with the ART should have the ability to bond effectively to enamel and dentine. This implied that the dental material used to produce the first ART restorations (polycarboxylate cement) was unsuitable, and that resin-and glass-ionomer-based materials were the only choices left. Although resin composite and compomer have been used with ART, most researchers have resorted to using hand-mixed auto-cured glass-ionomer cements; the most biocompatible plastic dental material available.13 Initially, those of a medium-viscosity type were used but, since the launch of a high-viscosity type in the mid-1990s, which showed improved physical properties, the former material was replaced by the latter. Dental practitioners should use high-viscosity glass-ionomers, both the powder-liquid and the encapsulated versions. They should select those that have been tested favourably in clinical studies of long duration, if they wish to produce ART restorations that will survive. However, they should know the physical strength of the material. A publication by Mickenautsch14 may be helpful in this search. Glass-ionomer cements mentioned most frequently in trials included in systematic reviews are those manufactured by GC, Japan and 3M ESPE, Germany.
Survival of ART restorations
The most recent meta-analyses on the performance of ART restorations, including data up until February 2010, showed cumulative survival rates for single-surface and multiple-surface ART restorations in primary teeth over the first 2 years as being 93% and 62%, respectively.15 Cumulative survival rates for single-surface ART restorations in permanent teeth over the first 3 and 5 years were 85% and 80%, respectively. Only three studies were available that had reported on multiple-surface ART restorations in permanent teeth, resulting in a one-year survival rate of 86%.15 These results hardly differed from the first meta-analyses that had been carried out five years earlier.16 A number of studies have been published since February 2010, but the results hardly influenced the outcomes from the 2010 meta-analyses. The conclusions regarding ART restoration survival are as follows:6
ART using high-viscosity glass-ionomer can safely be used in single-surface cavities in both primary and permanent posterior teeth;
ART using high-viscosity glass-ionomer cannot be routinely used in multiple-surface cavities in primary posterior teeth;
Insufficient information is available for conclusions about ART restorations in multiple-surfaces in permanent posterior teeth, and in anterior teeth in both dentitions;
The ART restoration criteria, used in most ART studies, are more stringent than other assessment criteria, such as the United States Public Health Services (USPHS) and the FDI criteria, and lead to lower survival result reports than would be obtained if these criteria were used.
The last statement is supported by a few studies,17,18,19 of which the longest-run ART restoration study provides the clearest example.19 ART restorations in adults had been assessed according to the ART restoration and the USPHS criteria. The survival rates of ART restorations for both assessment criteria are presented in Table 2 and show a big difference in survival rates, which is basically due to two aspects:
The ART restoration criteria fail a restoration when 0.5 mm of enamel is visible at the margin of the restoration; and
They fail a tooth re-restored by an outside dentist, which the other two sets of criteria do not fail.
ART Criteria Survival (%)
USPHS Criteria Survival (%)
Difference (%)
Single surfaces
65
87
22
Multiple surfaces
31
58
27
It is most likely that, had the USPHS criteria been applied to assess ART restorations instead of the ART restoration criteria, the survival rates of ART restorations would have been much higher than were reported. For the Zanata et al19 study, the difference was 22% and 27% for single-surface and multiple-surface ART restorations after 10 years, respectively.
ART restorations versus traditional restorations
Primary dentition
The number of studies that have compared ART with amalgam restorations in the primary dentition is low. The systematic review of Mickenautsch et al20 concluded that there was no difference between the two types of restoration. This systematic review was updated in 2012 and confirmed the conclusion of the former systematic review.21 Another recently published systematic review and meta-analysis related to multiple-surface ART restorations confirmed that the survival/success rates of high-viscosity glass-ionomer ART restorations were similar to those of the traditional treatments using amalgam or resin composites.22 The results of the most recently published study comparison of the ART using the high-viscosity glass-ionomer Ketac Molar Easymix (3M ESPE, Seefeld, Germany) and the traditional treatment using amalgam (Permite regular set, SDI, Melbourne, Australia) concurred with the conclusion of the systematic reviews. No significant difference in the survival of all types of restorations (77.3% for amalgam and 73.5% for ART after 2 years) was reported.23 Examples of ART restorations are shown in Figure 2.
Figure 2. ART restorations using Ketac Molar Easymix after 2 years.23(a) ODP ART restoration in tooth ULE at baseline; (b) after 1 year; (c) after 2 years. (d) Cavity occlusal tooth ULE; (e) cleaned cavity using ART; (f) ART restoration after 1 year; (g) after 2 years.
The systematic reviews and meta-analyses show that the longevity of ART restorations in primary teeth is not different from those produced in the traditional way, using either amalgam or resin composite. However, as the evidence was based on a relatively low number of quality studies, confirmation from further quality trials is needed.
Permanent dentition
Two meta-analyses related to the longevity of ART restorations concluded that:
There appeared to be no difference in survival rates between single surface ART restorations using glass-ionomer and amalgam restorations in permanent teeth over the first three years;24
The longevity of all types of ART restorations is equal to or greater than that of equivalent amalgam restorations for up to 6.3 years and is site-dependent.20
The latter conclusion was confirmed in a recent systematic review update.21 As in the comparison between ART and conventional approaches in primary teeth, there appears to be no difference between the two approaches in the longevity of single-surface restorations in permanent dentition. Very few studies have investigated the survival of multiple-surface ART restorations and no conclusion can therefore be drawn.15 Examples of ART restorations over time are presented in Figure 3.
Figure 3. ART restorations in occlusal surface after 5 years, using Fuji IX capsules,26 and 10 years, using Fuji IX powder-liquid.19(a) ART restoration after 3 months; (b) after 5 years; (c) at baseline; (d) after 10 years.
ART and secondary caries
Dentine carious lesion development at the margin of ART glass-ionomer restorations was reported to be low.18,19,25,26 This finding is supported by the results of the systematic review which showed that glass-ionomer had a higher caries-preventive effect than amalgam restorations in permanent teeth, with no difference in primary teeth.27 Many assumed that a high percentage of restorations would fail as a result of secondary caries, because decomposed dentine is sometimes left behind in the cavity after ART manual cleaning. The evidence presented, however, shows the opposite.
The ART approach is a practical, quality option for managing dentine cavities, alongside the traditional treatments, whether applied in the dental surgery or in the field. Current evidence restricts its unconditional use to the treatment of dentine cavities in single tooth surfaces.
Repair of ART restorations
In essence, the rules for repairing ART restorations are no different from those applied to repairing traditional restorations. For the latest update, the reader is referred to the FDI report on MID.3 The most important activity is the discovery of the reason(s) why a restoration has failed. If those have been identified, then they should not be repeated during the repair process. Repairing an ART restoration, in principle, is no different from treating a tooth cavity with ART for the first time. Therefore, the instruction presented in Table 1 should be followed when repairing an ART restoration.
Conclusion
Systematic reviews and meta-analyses have provided evidence for the high level of effectiveness of ART restoration, using high-viscosity glass-ionomer, to restore single-surface cavities, both in primary and in permanent posterior teeth. However, its effectiveness in restoring multiple-surface cavities in primary posterior tooth cavities needs to be improved. Insufficient information is available regarding the quality of ART restorations in multiple-surfaces in permanent anterior and posterior teeth. Evidence indicates no difference in the survival of single-surface high-viscosity glass-ionomer ART restorations and amalgam restorations. The use of ART results in comparable smaller cavities, and higher acceptance by children, of preventive and restorative care. Because no electricity and running water is required, ART restorations can be placed both in the field and in private practice, as has been documented in articles from Brazil, Japan, the Netherlands, South Africa, Turkey, the UK and the USA.
