ATRAUMATIC RESTORATIVE TREATMENT (ART)

INTRODUCTION It is based on modern knowledge about minimal invasion and minimal cavity preparation for carious lesion. It is a procedure based on removal of carious tooth tissue using hand instruments alone, and restoring the cavity with an adhesive restorative material. It was pioneered in Tanzania in mid 1980s, then followed by several community field tracks in Thailand (1991) and Zimbabwe (1993)

PRINCIPLES 2 main principles :

1. Remove carious tooth tissues using hand instruments only 2. Restoring the cavity with a restorative material that sticks to the tooth

Justification for usage of hand instruments:

ART is a biological approach; it requires minimal cavity preparation that conserves sound tooth tissues, thus resulting in less trauma to teeth Lower cost Limited pain; there is minimum need for local anesthesia and also reduces physiologic trauma Infection control is simplified because hand instruments can easily be cleaned and sterilized after every patient

Glass ionomer is used as restorative material because :

It adheres to BOTH enamel and dentin; reduces the need to cut sound tooth tissue to prepare the cavity Fluoride is released which prevents and arrests caries It is similar to hard oral tissues, it doesnt inflame the pulp or gingiva

INDICATIONS Only in small cavities where there is involvement of dentin In cavities that are accessible to hand instruments In public health programs

CONTRAINDICATIONS In presence of swelling (abscess) or fistula near the carious tooth Exposed pulp Chronic pain, there may be chronic inflammation of the pulp Obvious carious cavity is present but opening is inaccessible to hand instruments Clear signs of cavity but cannot be entered such as in proximal surfaces, but the cavity cannot be entered from the proximal or the occlusal

ADVANTAGES Minimal cavity preparation (conserves sound tooth structure, less trauma) Painless. This reduces the need for local anesthesia and less physiological trauma to patients Simplier infection control No need expensive equipment; ART can be practiced in remote areas and in the field A simple technique

Cost effective A friendly procedure It makes restorative care more accessible for all population group

PROCEDURE 1. . Arrange a good working environment Outside mouth o operators work posture and position o Assistance o Working alone o Patients head position Inside mouth

2. Hygiene and control of cross infection 3. Restoring the cavity a. Caries removal b. Conditioning the prepared cavity c. Mixing d. Precautions for GI material restoring the cavity e. Failed or defective restoration

1) Arrange a good working environment a) Outside the mouth i) Operators work posture and positions It should provide the best view of the inside of the patients mouth Operator should sit firmly on the stool with straight back, thighs parallel to the floor and both feet flat on the floor Head and neck should be still, the line between the eyes horizontal and the head slightly bent forwards to look at the patients mouth Adjust the height of the stool to the correct height for the eye focus of each operator. The distance from the operators eyes to the patients tooth is usually between 30 to 35 cm Operator should be positioned behind the patients head; the exact position depends on the area of the patients mouth that is to be treated

In an arc from 10 to 1 oclock position, the operator can perform all tasks. The most commonly used positions are direct rear (12 oclock) and right rear (10 oclock)

ii) Assistance Advantageous when treating children; help to mix the glass-ionomer while the operator concentrates on the cavity and maintain effective saliva control Assistant works on the left side of a right handed operator and does not change position Sit as close as possible to patient, facing the patients mouth Head should be 10-15 cm higher than the operator to allow them to see the operating field and also enables them to pass the correct instruments to the operator iii) Working alone Sit in appropriate position behind the patient A small table for holding the instruments and material; placed at the head end of patient or on the right hand side of the operator close to the patients body iv) Patient position A patient lying on the back on a flat surface will provide safe and secure body support, and a comfortable and stable position for lengthy periods of time Head rest for stabilization of the patients head in the desired position and also for the comfort of the patients If dental chair is not available, a very acceptable patient position is achieved by attaching a head support the end of the table Patient is positioned so that the saliva collects in the back of the oral cavity Operating field is now over the operators lap at the height of the operators chest v) patients head position 3 movements to provide good access and vision: Tilting head : backward tilt for access to the upper teeth : forward tilt for access to the lower teeth Turning the head : central position : left turn : right turn Mouth opening : fully open

: partly closed to allow relaxation of cheek muscle for better access to the buccal surfaces. The mirror is then used to hold the cheek away from the buccal surfaces vi) ) Operating light Light source : sun (natural) : artificial (more reliable, constant and can be focused ona particular spot) Therefore in a field setting, a portable light source is recommended b) Inside the mouth i) Control of saliva around the tooth being treated ii) Cotton wool rolls absorbs saliva and can provide short term protection from it

2) Hygiene and control of cross infection a) Place all instrument in water immediately after use b) Remove all debris from instruments by scrubbing with brush in soapy water. c) If autoclave is not available :

Prepare fire using available fuel

Take care when opening pressure cooker; release pressure first

Take instrument out with instrument forceps; dry with clean towel

Put instrument in pressure cooker with clean water 23cm depth

Remove pressure cooker from heat after 15 min and leave to cool

Store in a covered, preferably metal box

Place on stove and bring to boil. Heat for 15 min

Ensure that steam continues to be released

3) Restoring the cavity ~first, place cotton wool rolls alongside the tooth to be treated ~remove plaque from tooth surface with a wet cotton wool pellet ~dry the surface with dry pellet ~now, the extent of caries can be judged better a) Caries removal i) If cavity opening is very small, place a corner of the enamel hatchet blade in the cavity; then turn ii) Carious dentin can now be removed with excavator. iii) Remove soft caries by making circular scooping movements around the long axis of the instrument iv) Remove soft caries from DEJ before removing near pulp. Removing from DEJ may leave unsuported enamel with dentin v) Overhanging enamel can break easily; must be removed with hatchet. vi) Place instrument at the edge of enamel and fracture off small pieces vii) In multi surface cavity, a plastic strip is placed between the teeth; for making the correct contour of proximal surface. Soft wood wedge is placed between teeth at gum margin b) Conditioning the prepared cavity i) Dentin conditioner is for cleaning cavity walls; to improve chemical bonding of GI to tooth structure (10% solution of polyacrylic acid) ii) Apply 1 drop of conditioner on pad/slab iii) Dip pellet in it; clean entire cavity and adjacent fissures for 10-15 sec iv) If cavity is contaminated with blood, stop the bleeding by pressing with cotton pellet Wash blood with water and dry with cotton pellet Place dry cotton rolls on both sides of the tooth to prevent recontamination Reapply conditioner c) Mixing i) Place a spoonful of powder on glass slab ii) Divide powder into 2 equal portions iii) Dispense 2 drops of liquid next to powder. Hold the liquid bottle horizontal for a moment to allow air to escape from the tip, then move to a wertical position and allow the drop of liquid to fall onto the slab iv) Spread the liquid with spatula over a surface of 1.5-2 cm v) Start by adding of the powder vi) As soon as all powder particles are wetted, the 2nd portion is folded into the mix vii) Mixing time 20-30 sec

viii)

Final mixture should look smooth like chewing gum

d) Restoring the cavity i) Insert mixture into cavity in small amounts with blunt end of applier/ carver instrument to avoid inclusion of air bubbles ii) Push mixture into place with the round surface of an excavator making sure that the mixture goes into small cavities and under any enamel overhanging iii) Place a excess material on adjacent pit and fissures iv) Rub petroleum jelly on index finger v) Press the soft restorative material firmly into the cavity and fissures = press-finger technique vi) Remove the finger sideways after a few sec (displace excess material towards the slopes of cusps and between the cusps in direction of buccal/ lingual and proximal surfaces) vii) The time from the start of mixing until removal of finger should not be more than 1 minute. Remove any excess material with excavator. Dont disturb the restoration during hardening period. Check the bite after 1-2 minutes with articulating paper

ESSENTIAL INSTRUMENTS FOR ART

Instruments Mouth mirror

Use/ description To reflect light on operating field View cavity indirectly Retract cheek or tongue, as necessary Use : identify soft carious dentin Precaution : dont poke into very small carious lesion; may destroy tooth surface and caries arrestment process

explorer

tweezers Spoon excavator

Carry cotton wool rolls, pellets, wedges, articulating paper Use : for removing soft carious dentin Available in 3 sizes : small : dm approx 1mm

: e.g. Ash 153-154 : use in small cavities and cleaning DEJ : neck is rather fragile : break if too much force applied while excavating

medium : dm of spoon approx 1.5 mm : Ash 131-132 : removal of soft caries from larger cavities : push material into small cavities

large : dm approx 2 mm : Ash 127-128 : used in large cavities : remove excess material from restoration

Dental hatchet

Use : widen entrance to cavity : slice away unsupported and carious enamel

Applier/ carver

Width of blade approx 1 mm E.g. Ash 10-6-12

-a double-endded instrument with 2 functions : blunt end : insertion of GI material Sharp end : remove excess material, shape GI material E.g. Ash 6 special For mixing GI material 2 types of mixing pad : glass slab : disposable paper pad - Spatula is made of plastic; must bend so that it is easy to mix the

Mixing pad and spatula

powder and liquid rapidly and correctly cotton wool pellets Petroleum jelly For cleaning cavities Available in various sizes : size 4 ( smallest; for small cavities ) size 2 ( for larger cavities ) To keep moisture away from GI restoration to prevent examination gloves from sticking to GI as it sets hard For contouring the proximal surface of multi-surface restorations To hold the plastic strips close to the shape of proximal surface; prevent material from being forced between gums and teeth Should be shaped from soft wood Supplied as powder and liquid that must be mixed together: Powder : a glass-containing silicon oxide, aluminium oxide, calcium fluoride Liquid : polyacrylic acid OR demineralized water

Plastic strips

Wedges

Glass ionomer cement

FAILED/ DEFECTIVE RESTORATIONS Restoration completely missing Cause : Contamination with saliva or blood during restorative procedure Mixed material was too wet/ dry Not all of the soft caries had been removed Thin, undermined enamel that was left behind broke off Repair : Clean the cavity completely, apply dentin conditioner, refill the cavity

part of restoration has broken away Cause : Restoration was too high Air bubbles were trapped in the material during placement Repair : Clean the tooth surface &/or remaining restorative material Fill the gap with new mixture of GI material; ensure that restoration is not too high

restoration has fractured ~common in multiple surface restoration which is too high Repair depends on location of fracture line & mobility of fractured parts If fractured parts is can be removed, repair it as under previous heading If cant be removed, repair through ART is NOT POSSIBLE Need traditional treatment with drill

 restoration has worn away Cause : eating very hard food frequently Patient clenches his/ her teeth frequently Mixture was too wet/ dry Repair : ensure that all the surfaces of tooth and remaining restoration are clean Apply conditioner over GI and cavity walls Place a new layer of GI on top of the old one Finish the restoration

caries has developed in adjacent fissures or surface Remove the soft caries Clean & fill the new cavity adjacent to the restoration according to the standard procedures

SUMMARY In developing countries, carious teeth tend to go untreated; the only available option was extraction ART was developed to focus on the group of people who are unable to obtain restorative dental care ART is not a compromise, but a perfect alternative treatment approach for groups that are not able to obtain proper care.