explanation and procedure of atraumatic restoration

2. ATRAUMATIC RESTORATION
TREATMENT
By – Manmohan Singh
BDS Final Year
SGRD Dental College
Amritsar
Guided by :-
Dr. Satinder Singh Walia
Dr. Amaninder Kaur Randhawa

3. INTRODUCTION
• Atraumatic restorative treatment (ART) is defined as a minimally invasive care
approach in preventing dental caries and stopping its further progression – Given By
Jo E. Frencken, 2012.
• It is based on modern knowledge of :-
1. Minimal cavity preparation
2. Minimal invasion
3. Minimal intervention
for carious lesions..

4. HISTORY
• The ART approach was pioneered in Tanzania in the mid 1980s which was then
followed by several community field trails conducted in Thailand and Zimbabwe in
1991 and 1993 respectively.
• Results of the studies in Thailand and Zimbabwe have shown that 71% and 85% of
ART restorations remained in the teeth after 3 years.

5. WHY ART?
• The Atraumatic restorative treatment
(ART) technique or approach has
achieved considerable interest
worldwide, especially for its application
in developing countries where skilled
human and other resources are not
readily available or affordable to treat
dental caries by more conventional
means.

6. • The minimally-invasive procedure is largely pain-
free and readily accepted by children; and is also
gaining increasing acceptance in more developed
countries for the management of early childhood
caries. A recent study demonstrated the dramatic
improvements in oral health achieved in both the
primary and permanent dentitions of children
when the ART approach replaced the use of
conventional instrumentation in mobile dental
clinics. Even in some developed countries, many
children are deprived of adequate dental care
because of fear and for economic reasons.
• ART was officially endorsed by WHO in 1994.

7. PRINCIPLES
• The two main principles of ART are:
1. Removing carious tooth tissues using hand instruments only
2. Restoring the cavity with a restorative material that sticks to the tooth.
• Reason for using hand instruments?
1. the use of biological approach, which requires minimal cavity preparation that conserves sound tooth
tissues and causes less trauma to the teeth.
2. The low cost of hand instruments compared to electrically driven dental equipments.
3. The limitation of pain that reduces the need
for local anaesthesia to a minimum and reduces
psychological trauma to patients.
4. Simplified infection control. Hand instruments
can be easily cleaned and sterilized after every patient.

8. MATERIAL STICKING TO TOOTH !
• Glass-Ionomers are very useful restorative materials.
They are available as a powder and liquid that has to
be mixed together. Since they chemically (not
mechanically) bind to the teeth, the need to cut
sound tooth tissue to prepare the cavity is reduced.
These materials continue to release fluoride after
setting which has the added advantage of arresting
and preventing caries around the restorations.
Glass-ionomers are harmless to dentine, pulp and
gingiva. However compared with other materials
glass-ionomers are not strong enough and are
currently being improved by the manufacturers.

9. INDICATIONS
• ART is carried out
- Only in small cavities(involving dentin)
- In those cavities that are accessible to hand instruments
- Public health programs

10. ADVANTAGES
• ART is a biological approach that requires minimal cavity preparation that conserves
sound tooth tissues and causes less trauma to teeth.
• As ART is painless, the need for local anaesthetics are reduced and so is the
psychological trauma to patients.
• Simplifies infection control as hand instruments can easily be cleared and sterilized.
• No electrically driven and expensive dental equipment needed which enables ART
to be practiced in remote areas and in the field.

11. • This technique is simple enough to train non – dental personnel or primary health
care workers.
• ART approach is very cost effective.
• Since it is a friendly procedure, there are great potentials for its use among children,
fearful adults, physically and mentally handicapped and the elderly.
• It makes restorative care more accessible for all population groups.

12. CONTRAINDICATIONS
• ART should not be used when:
- there is presence of swelling or fistula near a carious tooth.
- the pulp of tooth is exposed.
- teeth have been painful for a long time and there may be chronic inflammation of
pulp.
- inaccessibility of hand instruments.

13. 1. Arrange a good
working environment
2. Hygiene and control
of cross infection
3. Restoring the cavity
PROCEDURE
Outside
the
mouth
Inside the
mouth

14. ARRANGING A GOOD WORKING
ENVIRONMENT
A) Outside The Mouth
• Working position of the operator
operator should sit back firmly and comfortably on the stool,
with straight back, thighs parallel to the floor and both feet flat
on the floor.
The head and neck should be still and slightly tilted.
Distance between the operator eye and the tooth should be 30 -
35 cm.
Operator should be positioned behind the head of the patient.
Operator should perform all task in 10 – 12’o clock position
* The following set of pictures are from an ART Manual prepared by Drs Jo Frencken, Prathip Phantumvanit, Taco Pilot,
Yupin Songpaisan and Evert van Amerongen and from Dr Yupin Songpaisan, Thailand.

15. • Assistance
The assistance work on the left side of a right handed
operator and does not change position.
Assistant’s head should be 10 – 15 cm higher than the
operator, so that the assistant can also see the
operating field and can pass the correct instruments
when needed.
IF WORKING ALONE THEN A SMALL TABLE IS PLACED
AT HEAD END FOR HOLDING INSTRUMENTS.

16. • Patients position
A patient lying on the back on a flat surface will provide
a safe and secure body support and a comfortable and
stable position for lengthy periods of time.
A head rest made up of firm foam or a rubber ring with
a cover can provide stability and desired position.
• Operating light
Light source can be natural or artificial.
Artificial can be a headlamp, glasses with light source
attached, light attached to mouth mirror.

17. • B) Inside the mouth
A very important aspect for the success of
ART is control of saliva around the
tooth being treated.
Cotton wool rolls are quite effective
at absorbing saliva and can provide
short term protection from moisture/saliva

18. HYGIENE AND CONTROL OF CROSS
INFECTION
• Universal infection control procedures should be followed.
In a field situation,
1. Place all the instruments in water immediately after use.
2. Remove all debris from the instruments by scrubbing with brush in soapy water. If an autoclave is
not available.
3. Prepare fire using the fuel available like wood, gas, charcoal, solar energy.
4. Put the clean instruments in a pressure cooker and add clean water to a depth of 2 – 3 cm from
bottom.
5. Place the pressure cooker on the stove and bring to boil. When the steam comes out from the vent,
put the weight in place. If available, set a timer for 15 mins.
6. Remove pressure cooker from the stove after 15 minutes, and leave it to cool.
7. Take instruments out and dry them with a clean towel. Store them in a covered, preferably metal
box.

19. RESTORING THE CAVITY
• Instruments needed are mouth mirror, explorer, a pair of tweezers, spoon excavator,
hatchet or hoe , applier/ carrier, mixing pad, spatula, cotton wool rolls, cotton wool
pellets, petroleum jelly, plastic strip, wedges, GIC and carver.

20. • Caries removal
The area around the carious tooth to be treated
is kept dry by placing cotton rolls.
If the opening in the enamel is small, widen the
entrance by placing the blade of the hatchet into
it and turning backward – forward like turning a
key in a lock.
Now with the excavator caries is removed.

21. • When all caries has been removed
and the cavity cleaned and dried a
dentine conditioner is applied on
the cavity to improve the bonding
of the filling material to the tooth.
• The glass-ionomer filling material
consists of powder and liquid
which is mixed on a glass slab or a
mixing pad. Mixing is completed in
20 - 30 seconds.

22. • The mixture is inserted to the cavity with
the flat end of the carver. The cavity is
over filled to include remaining pits and
fissures.
• Rub some petroleum jelly on the gloved
index finger and the filling material is
pressed firmly with the finger on the
tooth.
• The excess material is being removed
with a carver.
• The patient is not allowed to eat for at
least 1 hour. Note no anesthesia is used
and no dental drills are needed during
the whole procedure

23. PRECAUTIONS FOR GIC
• Disperse powder and liquid onto the slab only when cavity is properly prepared and
dried.
• Replace cap after use.
• Wipe nozzle of the liquid with damp gauze.
• If mixing is done for more than 30 sec the mixture looks dry, do not use it, because
there will be poor adhesion to tooth.
• Remove all GIC from dental instruments immediately after use before the material
has hardened, or put the instrument in water for easy cleaning.
• Each type of GIC have specific needs, therefor follow the manufacturer instructions.

24. FAILURE OF RESTORATION
• There may be many reasons for failure:-
 contamination with saliva or blood
 Mix too wet or dry
 All caries not removed
 Thin undermined enamel
 Too high restoration
 Trapped air bubbles
 Worned out restoration.

25. SUCCESS OF ART
• In a meta-analysis of 5 ART effectiveness studies, the retention of ART restorations
were compared to those using a conventional method in single surface restorations
in permanent dentition with a follow up of 2-3 years. Only one study found that the
survival rate of amalgams were significantly higher than ART. The 4 other studies
found that the difference in survival in the two techniques were not statistically
different.
• Survival rates of restorations using ART vary depending on several factors. In a
meta-analysis of studies reporting survival rates of ART restorations, single surface
restorations were found to be more successful than multi surface restorations in
both primary and permanent dentition. High viscosity glass ionomer was retained
longer than medium viscosity.

27. CONCLUSION
• ART is NOT a compromise but a perfect alternative treatment approach for
developing countries and special groups in the industrialized world.

28. Thank You