Restorative Dentistry

The atraumatic restorative treatment (ART) approach

for the management of dental caries
Roger J. Sinales, MDS, DDScVHak-Koiig Yip, BDS, MEd, MMedSc, PhD^
There is woridwide interest in and increasing usage of the conservative atraumatic restorative treatment
technique or approach for tiie restoration of primary and permanent teeth. However, most pubiished data
on the ciinicai performance of the newer, high-strength esthetic conventional glass-ionomer restorative
cements marketed for the procedure have been derived from short-term studies. There have been very
few reports comparing different types of restorative materiais and methods of cavity preparation, in
primary teeth, after 1 year, success rates have been approximateiy 80% to 95% for Ciass i and Class V
singie-SLJfface restorations, 55% to 75% for Ciass ii muifisurface resfcrations, and 35% to 55% for Class iii
and Ciass iV restorations, in permanent teeth, after 2 to 3 years, success rates have been approximately
90% for Class i and Class V singie-surface restorations, but iittie data have been reported for other
restorafion ciasses. Faiiures tjsuaiiy result from restoration iosses, fractures, and wear. Further improvements in the design of hand instruments and in the mechanicai properties of the newer glass-ionomer
cements are required. Currently, use of fhe atraumatic restorative treatment approach shouid be restricted
to restoration ot singie-suriace caries lesions, especiaiiy in permanent teeth, and to seaiing of occlusal
fissures in selected teeth, (Quintessence Int 2002:33:427-432)
Key words: atraumatic restorative treatment, dentai caries, giass-ionomer cement

he atraumatic restorative treatment (ART) technique or approach is an innovative, largely painfree, minimal intervention approach for treating cariotis teeth, particularly in countries where highly
trained dental personnel and the electricity needed for
clinical equipment are not readily available or affordable.' However, the method is also suitable for the
dental treatment of apprehensive children and disadvantaged groups in more developed countries, because
local anesthetic and dental handpieces are usually not
required .^-^
The ART approach was developed in Tanzania in
the mid-1980s; only hand instruments are used to
remove carious tooth substance before the cavity is
restored and any adjacent enamel fissures are sealed,
tisually with a conventional, self-hardening glassionomer cement (GIC).'' The minimally invasive pro-

'Visiling Research Feliow, Denial School, Faculty of Health Sciences,

Adeiaide Universily. Adelaide, South Australia. Australia.
'Associale Professor, Department of Oral Diagnosis, Faculty of Denlistry,
Prince Piiilip Dental Hospital. Hong Kong Special Administrative Region,
China.
Reprint requests: Dr Kevin H.-K. Yip, Department ol Oral Diagnosis,
Faculty of Dentistry, Prince Philip Dental Hospital, 34 Hospital Road. Hong
Kong Speciai Adrrinistrative Region, China. E-mait: hkyip@ni<usua.hku,hk

Quintessence internationai

cedure is largely pain-free and readily accepted by

children,^ ^ and GICs demonstrate sustained fluoride
release, pulpal biocompatibility, and chemical adhesion to tooth substance.""^
The GICs used in earlier field trials were not specifically developed for the ART approach, and the relatively high rate of failures found may have been partly
related to the materials and to the technical skills of
the operators.'"'^ Recently, several high-strength
esthetic conventional GICs with improved handling
and physical properties have been marketed for the
ART approach. The products release amounts of fluoride similar to the amount released by a metal-modified GIC, Ketac-Siivcr (ESPE), which is less than the
amounts released by earlier generation conventional
restorative GICs.'-^
The importance of operator training and close
attention to details of cavity preparation and placement of the cements when the ART approach is used,
together with aspects of preventive dental care, have
been emphasized/
In this review, the successes to date from field and
clinical studies of ART restorations and sealants
placed in the primary and permanent teeth of children
and adults are reviewed; some recommendations for
nature evaluations are also suggested.
427

 SmslesA'ip

TABLE 1 Survival rates (%) of atraumatic restorative treatment restorations and

sealants in permanent teeth
Class 1 and V
single-surface
Study

Trial

Time
(V)

Frencken et a l " ='

Field

Phantumvanit

Field

et al^='^6

Mallow et al'"
Limanowska-Shaw
et a l "
Holmgren et a P
Mandan et al^

Field
Field
Field
Field

3
3
3
2

Ho et aP

Clinic

Smith et al='

Field

Peng et al

Clinic

Sealant (fu , partial)

Material

Sur viva i

Caries

Survival

Caries

ChemFil Sup
Fuji iXChemFil [l
Amalgam
Fuji II
Fuji IX*

85(69-96)

2.2

50 (26-fi9)

8.4

88

NR

71

3.7

7t

8.6

50

NR

a5
61,67

8.8

NR

NR

NR

NR

NR

93

NR

NR

NR

Ketac-Molar
Fuji II
Amaigam
CliemFil Sup
Fuji IXMetal-GICs
Amalgam
Fuji IX GPKetac-Molar'
Amalgam

77-92

1.5

72

2.0

96

NR

NR

NR

92

NR

NR

NR

89

4.4

58

4.8

99

0.0

NR

5.7
NR
NR

100

0.0

94

0.0

100

0.0

97

0.0

100

0.0

NR

NR

93

1.8

71

97

0.0

NR

Glass-ioromer cements specifically marketedtortfie airaumatic restorative treatment approacti.

NR ^ not reported.

RESTORATIONS
Survival rates

Most of the puhlishcd ART studies of the newer highstrength esthetic conventional GfCs placed in primary
teeth have heen short term. After 1 year, success rates
have been approximately 80% to 95% for Class I and
Class V single-surface restorations, 55"/o to 75% for
Class II multisurface restorations, and 32''/o to 55% for
Class fll and Class IV restorations.i'-" After 2.5 years,
one follow-up study reported success rates of approximately 75% for Class I and Class V restorations, 54%
for Class II restorations, and 14% for Ciass Ilf and
Ciass IV restorations.'^' Two other studies reported
that, after 3 years, success rates were 100% for singlesurface and 55% for multisurface restorations'*" and
approximately 94% for Class 1 and Class II restorations and 15% for Class III restorations.'^ Generally,
the success rates for earlier generation GICs placed in
conventional Class H preparations in primary molars
have been very low, and amalgam restorations have
performed better.^"-"
The newer GICs marketed specifically for the ART
approach appear to he promising for the restoration of
single-surface caries lesions in permanent teeth (Table
1). After 2 to 3 years, the success rate reported by
428

most studies is approximately 90% for Class I and

Class V single-surface restorations; the rate for recurrent caries is approximately 2%. One recent 3-year
study reported higher survival rates for small restorations (92%) than for large restorations (77%),^' Studies
involving earlier formulations of GIC showed slightly
lower success rates (with higher caries}, as did restorations placed in children and in occlusal rather than
nonocclusal surfaces."''^'^s statistically significant
operator difterences have also been reported. "^^^^
Very few studies have reported the success rates for
Class II multisurface restorations in permanent teeth.
After 2 years, one study^' of an earlier GIC reported a
success rate of 69%. After 3 years, a much smaller
study'^ of Fuji IX (GC) used in a mixed age population
reported a very high success rate of 93%. Another
recent study of Ketac-Molar (ESPE) found that eight
of 14 Class II restorations were successful after 3
years."
Almost nothing is known of the success rates for
Class III and Class IV preparations in permanent
teeth. One study of Class III restorations after 3 years
found one surviving Fuji II restoration (GC} of four
assessed.'"
Only a few studies have compared the survival rates
of GIC restorations placed with the ART method and
amalgam restorations placed with the conventional

 SmalesA'ip

method in the same subjects or in similar populations.

Both 1- and 2-year studies have reported very high
and similar success rates for the two materials when
placed in single-surface occiusai preparations in permanent teeth.^*-^*'-'^ A 3-year study, however, found
that resuits were significantly better for amalgam
restorations,^^ Slightly better, but not significantly different, restilts have been reported for conventional
amalgam restorations than for ART method GIC
restorations placed in primary molars, both in Ciass I
preparations after I year'' and in Class II preparations
after 2 years,"
The newer high-strength GICs appear suitable for
the restoration of single-surface lesions in both primary and permanent teeth. However, the success rates
for GIC restorations in Class III and Class IV lesions
in primary teeth have been very poor, and insufficient
sttidies of the success of the ART method for other
^ e s of restorations have been reported,
Occiusai wear
Little information is available on the occlusal wear of
the newer high-strength esthetic GICs, One recent
study of restored primary molars reported cumuiative
net mean wear rates after 1 year of 66,5 40.4 pm for
Ftiji IX GP and 70,3 48-2 pm for ChemFlex
(Dentsply/DeTrey),'* These wear rates were higher
than those found for similar occlusal restorations in
the permanent teeth of the same subjects, and higher
than the threshold wear of 50 pm per year recommended by the American Dental Association's guidelines for posterior resin composites," After 1 year, the
tiet mean wear of permanent molar occlusal restorations was 774 47.0 pm for Fuji IX GP and 82,5
50,9 pm for Ketac-Molar.^" A similar study reported
tiet mean wear values of 61.4 38,9 pm after 1 year,
and 83,1 + 67.3 jmi after 2 years, for Fuji IX.^
These high and widely variahle wear rates may be
significant for the long-term clinical success of
occlttsal restorations in permanent teeth.

tion and the poor physical properties of the GICs.

Lack of retention is also commonly found in Class III
and Class IV ART preparations'^'-"' and where the
cements are used to restore shallow occiusai preparations and to seal occlusal pits andfissures,^It is sometimes difficult to achieve space for adequate hulk of
cement and macromechanical retention form when
the ART hand instruments are used,'^
In permanent molars, no failures of Class I GIC
restorations were found for either conventional rotary
or ART methods of cavity preparation after 1 year,'" In
another study of Class I GIC restorations over 2 years,
no statistically significant differences were found in
the success rates of conventional, modified-conventional, or ultraconservative preparation methods. The
last technique involved the use of Caridex CRS (MediTeam) and hand instnoments,^^
In all instances, the cavity preparation times for
GIC restorations are longer when ART hand instruments are used than when conventional rotary instruments are used (Table 2),
Although little information is available, failure of
some GIC restorations appears to be a combination
of inadequate cavity preparation with hand instruments to provide sufficient bulk and macromechanical retention and inadequate physical properties of
the materials to resist occlusal forces. Inadequate GIC
adhesion may also result from salivary contamination
and incomplete removal of dentin caries,^ ahhough an
in vitro study found that satisfactory caries excavation
is possible with ART instruments,'' These problems
may lead to loss of retention of the restorations, bulk
fractures, and brittle fatigue wear
Early, rapid occlusal wear results in liftle surface
and marginal staining and usually only minor marginal discrepancies.^'^''^'"^ A progressive color shift for
several of the newer conventional GICs over time has
also heen observed, but the clinical significance of this
change is not known,""
PIT AND FISSURE SEALANTS

Cavity preparations
Few studies have investigated the successes of difterent methods of cavity preparation for the newer
GiCs, either in the primary'^ or the permanent^*-'"'^'
dentitions.
After 1 year, the success rates for Class I preparations in primary molars were approximately 92% for
both conventional rotary and ART instrumentation
methods; for Class II preparations, however, the success rates were 87% for the conventional technique
and 79% for the ART method.'^ Faiiures occurred
from restoration losses because of inadequate retenQuintessence Inti

The use of GICs as fissure sealants placed with the

ART approach has heen studied in permanent teeth in
both field trials"^""' and clinical trials,''""' Early,
rapid losses of GIC sealant material were observed;
after 2 to 3 years, retention (full and partial) was usualiy approximately 50% to 70% and the rate of fissure
caries was approximately 4% to 8% (see Table 1).
These results appear to be better than those obtained
in earlier comparable studies of conventional GICs,'"''^
in vitro investigations have demonstrated the ability of the high-strength GICs to penetrate successfully
and to seal the occlusal fissures of molar teeth when
429

 SmalesA'ip

TABLE 2 Mean ( SD) times (min) for cavity preparation and tnaterial
placetnent

Study

Details

Atraumatic
restorative
treatment GIC

Conventional
GIC

Conventional
amalgam

Frencksn et a i ' '

Permanent teeth,
one surface

22.t (19.8-23.6)

NA

NA

Lo et a l "

Primary teeth

t0.54,0
10.8 3,6
9.1 2.1

NA
NA

NA

e.1 2.0

4.8 1.7

0.9 0.3

1.1 0.3

NA

6.5 1.9

Permanent teeth
Smaies et a i ^ "

Primary moiars.
one surface

Hong et aP^i

Permanent molars,
one sjrtace

2.1 0.3

Fang'5

Permanent molars,
one surface

11 9 3.2

NA

GIC = g lass, ionomer cement.

NA = not applicable.
No chairside assistance.
'Preparation limes on y, for small cavilies.
'No local analgesia u Bed.

the finger-press technique is used.^' Two field studies

of the ART approach have also shown the effectiveness of GIC sealants in preventing fissure caries in
selected teeth compared to unsealed teeth in the same
population." ^^ Although the bulk of the cement may
be lost, remnants may remain in the depths of the fissures, and this, together with fluoride on uptake into
the adjacent enamel, may confer some protection
against enamel caries, at least over the short term.*-

RECOMM EN DATIONS FOR FUTURE EVALUATIONS

Several items from the preliminary research agenda

for minimal intet^/ention techniques for caries'*"' have
been or are being addressed."^^ Although the results are
promising, short-term clinical studies have revealed
less than ideal restoration and sealant survival rates
for the GICs currently used with the ART approach.
There is a lack of long-term randomized ciinical trials
involving comparisons of techniques, restorative materials, and different at-risk population groups, to enable
accurate cost-effective analyses in terms of restoration
and sealant successes and teeth retained.
Alternative treatment methods could include the
use of topical fluorides for shallow, nonretentive cavities*^"*^ combined with other preventive measures.''^
Glass-ionomer cements with further improved
mechanical and adhesive properties are also needed,
as is the development of restorative materials to
actively promote remineralization and destroy cariogenic acid-producing microorganisms.
Exfoliated and extracted teeth that have been
430

restored through the ART approach require detailed

examination of the restorations and the restorationtooth interfaces to assess the adequacy of caries
removal and the ability of the materials to adapt
closely and to sea! the cavity walls.^^ Recently, the
importance of these factors in preventing caries progression has again been emphasized.^' The use of hand
instruments with larger, more ergonomie handles may
reduce operator finger and wrist fatigue'* and thereby
improve cavity preparation and caries excavation.
The criteria used to assess ART restorations and
sealants in field and clinical trials often differ from
study to study, making it difficult to compare findings;
more use should be made of the well-known US
Public Health Service {Ryge} method for direct clinical observations."'^''''^-^' Indirect clinical evaluations
should also be considered in clinical trials when more
objective assessments are required. Life table statistics
should be used for survival estimates to allow more
valid comparisons among studies.'''
CONCLUSION

Although newer, high-strength GICs are marketed by

manufacturers as definitive restorative materials for
use with the ART approach, some clinical problems
have become apparent over the short term. These
include the early loss of sealant material, the loss of
restorations from shallow and nonmacromechanically
retentive preparations, and bulk fracture of multisurface restorations. Further improvements in the
mechanical and adhesive properties of the newer
"02

 Smales/Yip

GICs are required to ensure their optimal long-term

clinical performance.
There is a need for long-term randomized clinical
trials involving different treatment techniques, restorative materials, and at-risk populations and both direct
and indirect assessment methods. Exfoliated and
extracted teeth require detailed examination to assess
the adequacy of the restorative procedures, including
the effects of leaving residual caries. Until further
studies are avaiiabie, it is recommended that the ART
approach he restricted to restoration of single-surface
caries lesions, especially in permanent teeth, and to
sealing of occlusal fissures in selected teeth.

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