ORIGINAL ARTICLE

International Dental Journal 2011; 61: 26 doi: 10.1111/j.1875-595X.2011.00001.x

Assessment of Atraumatic Restorative Treatment (ART) on the permanent dentition in a primary care setting in Nigeria
Olushola Ibiyemi1, Olubunmi Olusola Bankole2 and Gbemisola Aderemi Oke1
1 Department of Periodontology and Community Dentistry, University of Ibadan, Ibadan, Nigeria; 2Department of Child Oral Health, University of Ibadan, Ibadan, Nigeria

Objectives: To assess the acceptability of ART and to evaluate on a longitudinal basis the survival rate of single surface occlusal ART restorations in the permanent dentition. Design: Longitudinal Study of ART restorations. Setting: Primary Oral Health Care Setting. Participants: Aged 819 years in a low socioeconomic community, Southwestern Nigeria. Interventions/methods: Ninety-three ART restorations were applied on single surface occlusal caries by a dentist who had undergone training on ART. Main outcome measures: Six monthly follow-up of patients to evaluate restoration retention and marginal defect was conducted by an independent evaluator. Results: Over 90.0% of the subjects had never undergone dental treatment, yet 63.0% perceived dental treatment as painful. After undergoing the treatment as many as 98.0% admitted that ART was not painful. On the question of their willingness to make recall visits, about 95.0% responded in the affirmative and about 96.0% reported that they would encourage others to come for treatment. The cumulative survival rate of single surface occlusal ART restorations after 2 years was 93.5% (SE = 2.3%). Conclusions: ART was shown to be acceptable and effective in the management of single surface occlusal caries in the permanent dentition in these Nigerian children and adolescents outside the traditional clinical setting.
Key words: Single surface ART, permanent dentition, primary care setting

Nigeria is the most populous black country in the world, with a population of about 145 million1. It is a great challenge for the dental care delivery system to be able to cope with the oral health problems of this vast population. The dentist to patient ratio is very low and like many other developing countries the mal-distribution of oral health personnel remains a problem especially for rural populations. In Nigeria, conventional restorative care cannot be performed in many government-owned dental clinics because of lack of funds to purchase expensive equipment, lack of electricity and piped water, while in many private dental clinics the cost of this treatment makes it difcult for the populace to access restorative care. This may translate to high prevalence of untreated dental caries, pain, suffering, impaired functional ability, loss of man hours especially among school children and adolescents. This would ultimately result into tooth extraction and its attendant complications. In order to address a major aspect of the huge burden of untreated dental caries Atraumatic Restorative Treatment (ART) was developed, a restorative as well
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as preventive procedure which can be used in underprivileged communities as it requires minimal technological input2. The WHO Africa Ofce included ART in its strategic oral health policy guidelines 199920083 and Pan American Health Organisation (PAHO) recommended the use of ART to manage dental caries in Latin-American countries4. ART has been scientically tested and evaluated, involves neither drill, nor water, nor electricity and consists of manually cleaning dental cavities and lling them with adhesive bioactive uoride-releasing materials, after tooth surface conditioning5. Several eld and clinic based studies have shown ART to be successful in restoring one-surface carious lesions in permanent teeth in other parts of the world68. Some other studies9,10 further reported high survival rates of ART one surface restorations even in comparison with amalgam restorations. In Nigeria the only study carried out on ART was among pre-school children and it was clinic based in Metropolitan Lagos11. In this study, which spanned over a 1-year period, the success rate of ART restorations in primary teeth was high, showing that restor 2011 FDI World Dental Federation

ART in the permanent dentition in Nigeria ative dental care can be effectively provided to very young children. There has however not been any follow up for longer than 1 year and on occlusal carious lesions in the permanent dentition. Therefore, the present study aimed at investigating the survival rate of ART restorations on occlusal carious lesions in the permanent dentition in a Primary Health Care setting and over a longer period of 2 years. MATERIALS AND METHODS This longitudinal study was conducted at the Idikan area of Ibadan, the capital city of Oyo State in Southwestern Nigeria. Idikan with an estimated population of 40,000 is located in the inner city of Ibadan in a land space of approximately 100,000 sq meters12. It is predominantly a low socio-economic community. From a comprehensive list of state government owned schools in Idikan and its neighbouring communities, nine primary and ve secondary schools were randomly selected. After requisite institutional ethical clearance and informed consent, participants aged 8 19 years in these schools were enrolled in the study if they were found to have class 1 occlusal caries in permanent teeth on either side of the jaws, each cavity entrance being large enough to accommodate a small excavator (diameter 0.9 mm). The examination was carried out by two calibrated dentists in the classroom setting using dental mouth mirrors and wooden spatulas under bright natural light. Baseline records of dental caries of each participant were collected following WHO guidelines13. Repeat examinations of 20 individuals by the two examiners generated a Kappa statistic of 0.93 for inter-examiner reproducibility and 0.92 and 0.94 for the intra-examiner agreement on the DMFT scores. Teeth were excluded from ART if they exhibited signs of pulpal degeneration, such as history of pain, or the presence of a swelling or stula, or if they were judged to be unrestorable or had cavities with openings inaccessible to hand instruments. Deciduous carious teeth and any teeth found to be mobile were similarly excluded. On meeting the selection criteria, participants were engaged in an orientation exercise where they were educated on the importance and benet of ART and instructed on appropriate dietary practices by the team comprising the operator, a dentist and a chairside dental assistant. The ART application was undertaken following standard procedures6,14 which were adapted to the Primary Health Care setting using a locally fabricated adjustable dental chair. After participants received full prophylaxis, and ensuring a dry working eld by use of cotton wool rolls, access was achieved using enamel hatchets. Soft carious tissue was excavated using excavators. The cavity and associated ssures were washed
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with a wet cotton pellet and then blotted dry with a cotton pellet. Each cavity was then conditioned for 10 15 seconds using GC Dentine Conditioner containing polyacrylic acid solution and washed with a wet cotton pellet and then blotted dry with a cotton pellet. The recommended restorative materials for use in ART6,14, a hand-mixed high viscous glass ionomer cement, GC Fuji IX GP, was mixed according to the manufactures instructions and then packed into the cavity. The material was then condensed into the cavity, the adjacent pits and ssures thus providing a sealant restoration using a petroleum jelly coated index nger (press-nger technique)6,14. Excess restorative material was removed with an excavator or carver and the occlusion checked. Petroleum jelly (Vaseline) was used as a varnish to protect the restorations. Participants were instructed not to eat, drink or rinse the mouth until after 1 hour, to allow the ART restorations to set. No local anaesthesia was used for any of the restorations. Restorations were not assessed at the time of placement. On returning to the classroom after treatment, the subjects teacher was required to nd out from the student if there had been pain or discomfort during the treatment. They were also to elicit the childs willingness to undergo the same type of treatment subsequently. Follow-up of patients to evaluate restoration retention and marginal defect was conducted by an independent evaluator who was not the operator and who was also blinded to study group afliation at six months interval through to 2 years, using a torch light and CPITN probes. All follow-up examinations were conducted in the schools in order to minimise attrition. Duplicate examinations were carried out on a random sample of 10% of the subjects during each evaluation. Each restoration was assessed according to codes and criteria used in other ART studies6,14 as shown in Table 1. In interpreting the data, codes 0, 1 and 2 were considered to be Successful restorations whereas codes 3, 4, 5 and 6 were considered Failure. Codes 7 and 8 were excluded since restorations could not be assessed. When a lling was found to have failed at the six month Table 1 Codes and criteria used to evaluate ART restorations
Codes 0 1 2 3 4 5 6 7 8 Criteria Present, correct Present, slight marginal defect, no repair needed Present, slight wear, no repair needed Present, marginal defect >0.5 mm, repair needed Present, wear >0.5 mm, repair needed Not present, restoration partly or completely missing Not present, restoration replaced by another restoration Tooth is missing, exfoliated or extracted Restoration not assessed, child is not present

Measurement of the size of any marginal defect was done with the use of the 0.5-millimeter ball tip of CPITN (WHO) probe.
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Ibiyemi et al. review the patient was referred to the Primary Oral Health Care Center, Idikan for appropriate treatment. Data were entered and analysed using the Statistical Package for Social Science (SPSS) for windows version 1115. Frequencies, proportions and percentages were generated with respect to the quality of ART restorations. Cumulative survival rates were determined by the coded scores and standard criteria for evaluating ART restorations using KaplanMeier survival analysis. RESULTS A total of 93 ART restorations were placed in school children and adolescents, mean age 13.1 3.0 years at baseline. Prior to the placement of restorations, baseline data showed that about 91% of the participants had never had previous dental treatment, and 63% reported that dental treatments were painful prior to the present encounter thus they were afraid of receiving treatment. However, after treatment about 95% of the participants were willing to receive ART restorations again and about 96% reported that they would encourage others with similar problem to attend for the same treatment. Results of the duplicate examinations on restoration status showed excellent intra-examiner reproducibility with kappa values ranging from 0.90 to 0.92 in the different evaluations. The dropout rate was very low as over 98% of the restorations were evaluated during each of the follow-up assessments. The number of restorations evaluated at year 1 and 2 were 93 and 92 respectively. In Table 2, the status of ART restorations after 1 year and 2 years shows that the majority of restorations that were successful were in good condition while most of the restorations that failed were partly or completely missing. The cumulative survival rates of ART restorations placed with conditioners are presented in Figure 1. The 1 year and 2 year cumulative survival rates were 99.3% (SE = 0.5%) and 93.5% (SE = 2.3%) respectively.
1.0

0.8

Cumulative survival (%)

0.6

0.4

Survival function Censored

0.2

0.0 5.00 10.00 15.00 20.00 25.00

Time (in months)

Figure 1. Cumulative survival curve of occlusal surface ART restorations placed with conditioners in permanent dentition over the 2-year period.

DISCUSSION In this study, the dropout rate was <5% which is low compared to other studies6,8,9 which reported at least 10% dropout. This is probably because follow-ups were done in school premises. Furthermore, teachers, parents and subjects were very supportive and eager to see the outcome of the study. Only one subject was lost to follow up as the family moved in the course of the study. One major deterrent to health seeking behaviour especially for dental care is fear or perception of pain16. This has been supported by the ndings of this study in that the vast majority of the participants, even though they claimed they had never visited the dentist expressed immense fear and a wrong notion of what dental treatment experience should be. It is gratifying to note however that in spite of this initial bias, most of them admitted to having a pleasant experience compared to this preconceived attitude. Furthermore, they would be willing to receive such treatment again and would encourage others to patronise the dentist for similar procedures. These observations were also reported in other previous studies16,17 conducted in environments with similar socio-demographic characteristics. ART is carried out using few hand instruments and without local anaesthetic injections and drills. Studies have shown that dental anxiety is mainly associated with highly invasive procedures such as drilling and injections18,19. This is why several studies have reported that children treated according to the
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Table 2 Status of the ART restorations after 1 year and 2 years expressed in percentages
Status of ART restorations Success, in good condition Success, slight marginal defect Success, slight wear Failed, gross marginal defect Failed, gross wear Failed, partly or completely missing Failed, replaced by another lling Total 1 year, n (%) 84 5 2 0 0 2 0 93 (90.3) (5.5) (2.1) (0) (0) (2.1) (0) 2 years, n (%) 79 5 5 1 0 2 0 92 (85.9) (5.4) (5.4) (1.1) (0) (2.2) (0)

A patient emigrated and was excluded in the 2nd year analysis.

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ART in the permanent dentition in Nigeria ART approach using hand instruments alone experience less discomfort than those treated using rotary instruments since local anaesthesia is rarely used16,20. This could explain the better acceptability of the procedure. Due to lack of discomfort from the use of ART, it may be a very useful tool when treating high caries risk patients, children and disadvantaged patients, such as special care patients, the elderly and those who have experienced discomfort, anxiety or pain. In this study, ART restorations were very successful in restoring single surface occlusal lesions in the permanent dentition, with 1 year and 2 years cumulative survival rates of 99.3% and 93.5% respectively. These were in agreement with previous studies that reported very similar survival rates2123. Previous ART researchers17,24 reported that the success rate for ART restorations depends on the material used, training of the operator, and extent of caries. Frencken et al.25 noted that the high success rate of ART restorations was due to high strength materials used, chairside assistant availability and placement of the restorations by trained operators. These might also be the reasons for the observed high success rate of ART restorations in this study. The 1-year and 2-year success rates of ART restorations in this study were higher than the results from some previous studies where lower strength ART materials were used and untrained or lower skilled operators applied the ART restorations6,7. The majority of successful restorations in this study were assessed to be in good condition while the reasons for failure were complete or partial loss of restorations and gross marginal defect as in other studies10,23. Gross wear accounted for fewer failures as in other studies because a high strength GIC was used8,9. No restoration was replaced by another lling because the level of awareness to oral health of people in this community was low resulting in poor oral health care seeking behaviour. This study was carried out in a primary care setting where electricity is a challenge. Findings showed that it is both feasible and practical to use ART in restoring carious permanent teeth. This conforms with the original idea of early researchers by providing restorative dental care outside the traditional clinical setting to people who would not normally have access to dental care5,6. It is strongly recommended that future ART studies in this environment should include multiple surfaces and comparison should be made with conventional amalgam restorations. There is a need to assess the long term effect of ART in Nigeria as in other countries10,26 where 57-years survival rates have been reported to be high. In conclusion, the ndings in this study also support the reports of previous studies that the ART is effective, acceptable and feasible for the management of singlesurface occlusal cavities in permanent dentition in rural and suburban areas in less industrialised countries23,25.
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The ART approach has been well received by children and adolescents who belong to population groups not previously exposed to regular oral health care. Followup care with topical uorides and oral hygiene instruction will improve the treatment outcome of high cariesrisk dental populations. The 2-year survival rate of ART in this study is high enough to recommend its wide use in Nigeria. Primary health care settings and outreach dental services with emphasis on prevention should be encouraged to adopt ART as a practical and effective means for providing restorative dental care to children and adolescents outside the traditional clinical setting but this has to be validated by other studies. Acknowledgements The authors are grateful to the Ministry of Education, Oyo State and the Principals and Head Teachers of the schools used for this study for their help and enthusiastic cooperation, encouragement and support. We are sincerely grateful to all the study participants and their parents and guardians for their cooperation. REFERENCES
1. Malomo AO, Ogundiran TO, Jegede A et al. The Nigerian experience. J Acad Ethics 2008 6: 305309. 2. World Health Organisation. Revolutionary new procedure for treating dental caries. Press Release WHO 28 1994 Apr 7. 3. WHO Regional Ofce for Africa. Oral Health in the African Region. A Regional Strategy 19992008. Harare: World Health Organisation Regional Office for Africa; 2000. 4. PAHO. Oral health of low income children. Procedures for Atraumatic Restorative Treatment. Final Report. Washington DC: Pan American Health Organisation; 2006. 5. Frencken J, Makoni F. A treatment technique for tooth decay in deprived communities. World Health 1994 47: 1517. 6. Phantumvanit P, Songpaisan Y, Pilot T et al. Atraumatic Restorative Treatment (ART): a three-year community eld trial in Thailand survival of one-surface restorations in the permanent dentition. J Public Health Dent 1996 56: 141145. 7. Mallow PK, Durward CS, Klaipo M. 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 Paediatric Dent 1998 8: 3540. 8. Lopez N, Simpser-Rafalin S, Berthold P. Atraumatic Restorative Treatment for prevention and treatment of caries in an underserved community. Am J Public Health 2005 95: 13381339. 9. Holmgren CJ, Lo EC, Hu D et al. ART restorations and sealants placed in Chinese school children-results after three years. Comm Dent Oral Edpidmiol 2000 28: 314320. 10. Mandari GJ, Frencken JE, vant Hof MA. Six year success rates of occlusal amalgam and glass-ionomer restorations placed using three minimal intervention approaches. Caries Res 2003 37: 246 253. 11. Agbaje MO. Clinical evaluation of Atraumatic Restorative Treatment in Pre-School Children in Lagos State. In: Department of Child Oral Health. National Postgraduate Medical College of Nigeria: Lagos; 2005. p. 8993. 12. Aderinokun GA, Lawoyin JO, Faseemo VO et al. Prevalence of tetracycline stained teeth amongst some school children in Ibadan, Nigeria. Niger Med Pract 1994 27: 7375.
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13. World Health Organisation. Oral Health Surveys: Basic Methods, 3rd edn. Geneva: WHO; 1988. 14. University of Groningen. Guidelines for Protocols for Clinical Studies of the Atraumatic Restorative Treatment (ART): Technique and Materials. The Netherlands: WHO Collaborating Center for Oral Health Services Research, University of Groningen; 1995. 15. Statistical Package for Social Science. Statistical Package for Social Science for Windows. Release 7.5 (Nov. 14 1996) standard version. Chicago, IL: Statistical Package for Social Science; 1989 1996. 16. Schrinks MCM, van Amerongen WE. Atraumatic perspective of ART: psychological and physiological aspects of treatment with and without rotary instruments. Community Dent Oral Epidemiol 2003 31: 1520. 17. Kikwilu EN, Frencken J, Mulder J. Impact of Atraumatic Restorative Treatment (ART) on the treatment prole in pilot government dental clinics in Tanzania. BMC Oral Health 2009 9: 14 doi: 10.1186/1472-6831-9-14. 18. Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1973 86: 842848. 19. Berge M, Hoogstraten J, Veerkamp JSJ et al. The dental subscale of the childrens fear survey schedule: a factor analytic study in the Netherlands. Community Dent Oral Epidemiol 1998 26: 340343. 20. Deery C. Atraumatic restorative techniques could reduce discomfort in children receiving dental treatment. Community Dent Oral Epidemiol 2003 31: 1520. 21. Abid A, Chkir R, Ben Salem K et al. Atraumatic Restorative Treatment and glass ionomer sealants in Tunisian children: survival after 3 years. East Mediterr Health J 2002 8: 315323. 22. Vant Hof MA, Frencken JE, van Palenstein Helderman WH et al. The Atraumatic Restorative Treatment (ART) approach for managing dental caries: a meta-analysis. Int Dent J 2006 56: 345351. 23. Smales RJ, Yip HK. The Atraumatic Restorative Treatment (ART) approach for the management of dental caries. Quintessence Int 2002 33: 427432. 24. Louw AJ, Sarvan I, Chikte UME et al. One year evaluation of Atraumatic Restorative Treatment and minimum intervention techniques on primary teeth. South Afr Den J 2002 57: 366371. 25. Frencken JE, Holmgren CJ. ART: a minimal intervention approach to manage dental caries. Dent Update 2004 31: 295 298, 301. 26. Frencken JE, vant Hof MA, Taifor D et al. Effectiveness of ART and traditional amalgam approach in restoring single-surface cavities in posterior teeth of permanent dentitions in school children after 6.3 years. Community Dent Oral Epidemiol 2007 35: 207214.

Correspondence to: Dr. O. Ibiyemi, Department of Periodontology and Community Dentistry, University of Ibadan, PMB 5017 GPO Dugbe Ibadan, Nigeria. Email: shola_ibiyemi@yahoo.com

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