Jo E. Frencken

Effectiveness of Single-surface ART Restorations in the Permanent Dentition : A Meta-analysis

Over the past few years, there has been an increase in the number of studies reporting on various aspects of the Atraumatic Restorative Treatment (ART) approach. Five randomized clinical trials in which ART restorations with glass ionomers were compared with amalgam restorations in permanent teeth for a maximum period of 3 yrs constituted the database. This meta-analysis divided the publications into ‘early’ (1987–1992) and ‘late’ (1995-) studies on the basis of improvements in the approach. The analysis showed that, in the ‘early’ studies, single-surface amalgam restorations survived statistically significantly longer than comparable ART restorations after 1, 2, and 3 yrs. This trend did not continue into the late group of studies; no statistically significant difference between the 2 types of restorations was found. Based on the available data, it appears that there is no difference in survival results between single-surface ART restorations and amalgam restorations in permanent teeth over the first 3 yrs.

Minimal intervention dentistry for managing dental caries - a review: report of a FDI task group.

This publication describes the history of minimal intervention dentistry (MID) for managing dental caries and presents evidence for various carious lesion detection devices, for preventive measures, for restorative and non-restorative therapies as well as for repairing rather than replacing defective restorations. It is a follow-up to the FDI World Dental Federation publication on MID, of 2000. The dental profession currently is faced with an enormous task of how to manage the high burden of consequences of the caries process amongst the world population. If it is to manage carious lesion development and its progression, it should move away from the surgical care approach and fully embrace the MID approach. The chance for MID to be successful is thought to be increased tremendously if dental caries is not considered an infectious but instead a behavioural disease with a bacterial component. Controlling the two main carious lesion development related behaviours, i.e. intake and frequency of fermentable sugars, to not more than five times daily and removing/disturbing dental plaque from all tooth surfaces using an effective fluoridated toothpaste twice daily, are the ingredients for reducing the burden of dental caries in many communities in the world. FDIs policy of reducing the need for restorative therapy by placing an even greater emphasis on caries prevention than is currently done, is therefore, worth pursuing.

Effectiveness of Glass-Ionomer (ART) and Amalgam Restorations in the Deciduous Dentition: Results after 3 Years

This study compared the survival of restorations produced through the atraumatic restorative treatment (ART) approach using glass-ionomer with those produced through the traditional approach using amalgam (MTA) in deciduous dentitions over a period of 3 years. Using a parallel group design, 835 grade 1 children, aged 6–7 years, participated. A total of 482 children were treated through the ART and 353 children through the MTA approach. Eight dentists produced a total of 1,891 single- and multiple-surface restorations. After 3 years, 22.1% of the restorations were lost for evaluation. There was a statistically significant difference in the combined survival of all single- and multiple-surface restorations between the two approaches in favour of the ART approach (p = 0.04). The study revealed a 3-year cumulative survival percentage of single-surface ART and MTA restorations of 86.1 and 79.6%, respectively. The difference was statistically significant (p = 0.03). The main reasons for both single-surface ART and MTA restorations to fail was ‘restoration missing’ followed by ‘gross marginal defect’. The 3-year cumulative survival percentages of multiple-surface ART and MTA restorations were 48.7 and 42.9%, respectively. The difference was not statistically significant (p > 0.05). The 3-year survival percentages of single- and multiple- surface ART and MTA restorations varied widely amongst the 8 operators with an operator effect (p = 0.001) for multiple-surface MTA restorations. It can be concluded that the ART approach using glass-ionomer yielded better results in treating dentinal lesions in deciduous teeth than did the traditional approach using amalgam after 3 years. It is recommended to select the ART approach to complement the other activities of the school oral health programme.

Survival of atraumatic restorative treatment (ART) sealants and restorations: a meta-analysis

The purpose of this study is to perform a systematic investigation plus meta-analysis into survival of atraumatic restorative treatment (ART) sealants and restorations using high-viscosity glass ionomers and to compare the results with those from the 2005 ART meta-analysis. Until February 2010, four databases were searched. Two hundred four publications were found, and 66 reported on ART restorations or sealant survival. Based on five exclusion criteria, two independent reviewers selected the 29 publications that accounted for the meta-analysis. Confidence intervals (CI) and or standard errors were calculated and the heterogeneity variance of the survival rates was estimated. Location (school/clinic) was an independent variable. The survival rates of single-surface and multiple-surface ART restorations in primary teeth over the first 2xa0years were 93% (CI, 91–94%) and 62% (CI, 51–73%), respectively; for single-surface ART restorations in permanent teeth over the first 3 and 5xa0years it was 85% (CI, 77–91%) and 80% (CI, 76–83%), respectively and for multiple-surface ART restorations in permanent teeth over 1xa0year it was 86% (CI, 59–98%). The mean annual dentine lesion incidence rate, in pits and fissures previously sealed using ART, over the first 3xa0years was 1%. No location effect and no differences between the 2005 and 2010 survival rates of ART restorations and sealants were observed. The short-term survival rates of single-surface ART restorations in primary and permanent teeth, and the caries-preventive effect of ART sealants were high. Clinical relevance: ART can safely be used in single-surface cavities in both primary and permanent teeth. ART sealants have a high caries preventive effect.

Managing Carious Lesions: Consensus Recommendations on Carious Tissue Removal

The International Caries Consensus Collaboration undertook a consensus process and here presents clinical recommendations for carious tissue removal and managing cavitated carious lesions, including restoration, based on texture of demineralized dentine. Dentists should manage the disease dental caries and control activity of existing cavitated lesions to preserve hard tissues and retain teeth long-term. Entering the restorative cycle should be avoided as far as possible. Controlling the disease in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal or control first. Only when cavitated carious lesions either are noncleansable or can no longer be sealed are restorative interventions indicated. When a restoration is indicated, the priorities are as follows: preserving healthy and remineralizable tissue, achieving a restorative seal, maintaining pulpal health, and maximizing restoration success. Carious tissue is removed purely to create conditions for long-lasting restorations. Bacterially contaminated or demineralized tissues close to the pulp do not need to be removed. In deeper lesions in teeth with sensible (vital) pulps, preserving pulpal health should be prioritized, while in shallow or moderately deep lesions, restoration longevity becomes more important. For teeth with shallow or moderately deep cavitated lesions, carious tissue removal is performed according to selective removal to firm dentine. In deep cavitated lesions in primary or permanent teeth, selective removal to soft dentine should be performed, although in permanent teeth, stepwise removal is an option. The evidence and, therefore, these recommendations support less invasive carious lesion management, delaying entry to, and slowing down, the restorative cycle by preserving tooth tissue and retaining teeth long-term.

Twenty-five-year atraumatic restorative treatment (ART) approach: a comprehensive overview

BackgroundThe atraumatic restorative treatment (ART) approach was born 25xa0years ago in Tanzania. It has evolved into an essential caries management concept for improving quality and access to oral care globally.ResultsMeta-analyses and systematic reviews have indicated that the high effectiveness of ART sealants using high-viscosity glass ionomers in carious lesion development prevention is not different from that of resin fissure sealants. ART using high-viscosity glass ionomer can safely be used to restore single-surface cavities both in primary and in permanent posterior teeth, but its quality in restoring multiple surfaces in primary posterior teeth cavities needs to be improved. Insufficient information is available regarding the quality of ART restorations in multiple surfaces in permanent anterior and posterior teeth. There appears to be no difference in the survival of single-surface high-viscosity glass-ionomer ART restorations and amalgam restorations.DiscussionThe use of ART results in smaller cavities and in high acceptance of preventive and restorative care by children. Because local anaesthesia is seldom needed and only hand instruments are used, ART is considered to be a promising approach for treating children suffering from early childhood caries. ART has been implemented in the public oral health services of a number of countries, and clearly, proper implementation requires the availability of sufficient stocks of good high-viscosity glass ionomers and sets of ART instruments right from the start. Textbooks including chapters on ART are available, and the concept is being included in graduate courses at dental schools in a number of countries. Recent development and testing of e-learning modules for distance learning has increasingly facilitated the distribution of ART information amongst professionals, thus enabling more people to benefit from ART. However, this development and further research require adequate funding, which is not always easily obtainable. The next major challenge is the continuation of care to the frail elderly, in which ART may play a part.ConclusionART, as part of the Basic Package of Oral Care, is an important cornerstone for the development of global oral health and alleviating inequality in oral care.

Survival of ART and Amalgam Restorations in Permanent Teeth of Children after 6.3 Years

The null hypothesis tested was that there is no difference in the survival percentages of all restorations placed through the Atraumatic Restorative Treatment (ART) approach, with high-viscosity glass ionomer, and those produced through the traditional approach, with amalgam (TA), in the permanent dentitions of children after 6.3 years. Using a parallel group design, we randomly assigned a total of 370 children, aged 6 to 9 years, to the ART group and 311 children, also aged 6 to 9 years, to the TA group. Eight dentists placed a total of 1117 single- and multiple-surface restorations. The cumulative survival percentages for ART glass-ionomer restorations were statistically significantly higher than those of amalgam restorations at all time intervals except the first (p ≤ 0.044). After 6.3 years, the cumulative survival percentages of ART and amalgam restorations were 66.1% (SE = 3.1%) and 57.0% (SE = 3.3%), respectively. We concluded that the restorations produced with the ART approach, with high-viscosity glass ionomer, survived longer than those produced with the traditional approach, with amalgam, in the permanent teeth of young children.

Managing Carious Lesions: Consensus Recommendations on Terminology

Variation in the terminology used to describe clinical management of carious lesions has contributed to a lack of clarity in the scientific literature and beyond. In this article, the International Caries Consensus Collaboration presents 1) issues around terminology, a scoping review of current words used in the literature for caries removal techniques, and 2) agreed terms and definitions, explaining how these were decided. Dental caries is the name of the disease, and the carious lesion is the consequence and manifestation of the disease—the signs or symptoms of the disease. The term dental caries management should be limited to situations involving control of the disease through preventive and noninvasive means at a patient level, whereas carious lesion management controls the disease symptoms at the tooth level. While it is not possible to directly relate the visual appearance of carious lesions’ clinical manifestations to the histopathology, we have based the terminology around the clinical consequences of disease (soft, leathery, firm, and hard dentine). Approaches to carious tissue removal are defined: 1) selective removal of carious tissue—including selective removal to soft dentine and selective removal to firm dentine; 2) stepwise removal—including stage 1, selective removal to soft dentine, and stage 2, selective removal to firm dentine 6 to 12 mo later; and 3) nonselective removal to hard dentine—formerly known as complete caries removal (technique no longer recommended). Adoption of these terms, around managing dental caries and its sequelae, will facilitate improved understanding and communication among researchers and within dental educators and the wider clinical dentistry community.

The ART approach using glass-ionomers in relation to global oral health care

Dental caries is the most prevalent non-communicable disease in the world. Its management in high-income countries over the last four decades has resulted in relatively low caries prevalence in child and adolescent populations. In low- and middle-income countries, caries management is virtually non-existent and this may lead to serious physical and mental complications, particularly in children. Toothache is predominantly treated by extracting the cavitated tooth. Absence of restorative oral care is partly due to the copying from high-income countries, of restorative treatment reliant on electrically driven equipment and often inappropriate for use in many low- and middle-income countries. Atraumatic Restorative Treatment (ART), which does not rely on electrically driven equipment, has yielded good results over the last two decades. ART uses hand instruments and high-viscosity glass-ionomers. Its introduction into public oral healthcare systems has been piloted in several countries. Initial short-term results show that the introduction of ART, using high-viscosity glass-ionomers, has increased the ratio of restorations to extractions. Moreover, the percentage of ART restorations in relation to the total number of restorations placed increased steeply after its introduction and has remained high. However, ART introduction faced a few barriers, the most important being high patient workloads and the absence of a constant supply of dental instruments and glass-ionomers. High-viscosity glass-ionomer has become an essential element in public oral healthcare systems, particularly in those operating inadequately.

Clinical and SEM assessment of ART high-viscosity glass-ionomer sealants after 8-13 years in 4 teeth.

OBJECTIVESnResin composite sealants are retained longer than low-viscosity glass-ionomer sealants. Nevertheless, a systematic review showed that there is no evidence that resin composite sealants are superior to low-viscosity glass-ionomers in preventing dentine carious lesion development. This case study aimed to investigate reasons for this.nnnMETHODSn4 teeth were sealed with 2 brands of high-viscosity glass-ionomer according to the ART technique in 2 children aged 10 and 11.5 years, having a low caries-risk status, and followed clinically for between 8 and 13 years. At the final year, impressions were taken for SEM images that were assessed by two evaluators.nnnRESULTSnPits and fissures that were clinically diagnosed as free of sealant material appeared to contain remnants of high-viscosity glass-ionomer sealant material in the deeper parts of pits and fissures, on SEM images of 3 teeth.nnnCONCLUSIONnThis study confirms the likelihood that remnants of high-viscosity glass-ionomer sealant material are retained and block the deeper parts of pits and fissures even after the sealant appears to have disappeared clinically, exercising their carious lesion preventive effect.