Less drilling! More healing!

27-05-2013

Caries management through the Atraumatic Restorative Treatment (ART) approach and glass-ionomers: Rationale and Evidence

Jo E. Frencken, BDS, MSc, PhD 

Department of Global Oral Health, College of Dental Sciences, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands. Tel: +31-24-361.4050; fax: +31-24-354.0265. j.frencken@dent.umcn.nl

Key words: atraumatic restorative treatment, ART, sealant, glass-ionomer sealant, resin sealant, ART restoration, amalgam restoration, composite restoration

Jo Frencken 3.3

ART restoration at baseline!

Jo Frencken 3.4

ART restoration after 10 years !

Introduction

The Atraumatic Restorative Treatment (ART) can be defined as a minimal intervention approach to both prevent dental caries and to stop its further progression. It consists of two components: sealing caries prone pits and fissures (ART sealants) and restoring cavitated dentin carious lesions with sealant-restorations (ART restorations). The placement of an ART sealant involves the application of a high-viscosity glass-ionomer that is pushed into the pits and fissures under finger pressure. An ART restoration involves the creation of sufficient access to the cavity for the removal of soft, completely demineralised (decomposed) carious tooth tissue with hand instruments only. This is followed by restoration of the cavity with an adhesive dental material that simultaneously seals any remaining pits and fissures that remain at risk (Frencken et al, 1996)1. In the early years, a medium-viscosity glass-ionomer was the only suitable material available. The insertion of this type of glass-ionomers in stress bearing tooth surfaces trigged manufacturers to develop a more wear resistant glass-ionomer. These so called high-viscosity glass-ionomers were introduced in the mid nineties are still the type of glass-ionomer required with ART.

ART is less anxiety and pain provoking, compared to the traditional restorative treatments, and administration of local anesthesia is limited if the ART protocol is carried out correctly (Leal, 2009)2. Using the ART, caries control can be performed in the dental surgery but also in the field (school, villages) as no electricity and running water is required.

ART sealants

A sealant, in principle, is placed to allow easy plaque removal from pits and fissures systems otherwise difficult to clean. A sealant changes a morphological uneven surface into a smooth surface. The indication for placing an ART sealant, in principle, is not different from that for placing a resin-based sealant. However, glass-ionomers are more hydrophilic in nature than resin-based materials. It is therefore logical to assume that a glass-ionomer rather than a resin-based material should be used in sealing caries-prone pits and fissures which cannot be kept absolutely moist-free, such as in erupting molars and in children with behavior problems. Examples of sealants placed according to the ART protocol using a high-viscosity glass-ionomers over many years are presented in figure 1.

How effective are ART sealants?

With the launch of high-viscosity glass-ionomers for use with ART sealants (Frencken et al, 1998),3 the retention rate of glass-ionomer (ART) sealants has increased substantially in comparison to those of the low- and medium-viscosity glass-ionomers previously used (Van ‘tHof et al, 2006).4 A meta-analysis concluded that the mean annual failure rate of completely lost high-viscosity glass-ionomer ART sealants over the first three years was 9.3% (De Amorim et al, 2012).5

Despite the substantial annual loss of sealant material, only 1% of these ART sealants failed per year (De Amorim et al, 2012).5  Compared to resin-based sealants, three systematic reviews and meta analyses, which had included high-viscosity glass-ionomer ART sealants, showed that there is no evidence that the dentine carious lesion-preventive effect of resin-based sealants is better than that of glass-ionomer-based sealants (Beiruti et al, 2006; Yengopal et al, 2009; Mickenautsch and Yengopal, 2011).6-8  This finding might, in part, be ascribed to the presence of remnants of glass-ionomer observed in the deeper parts of pits and fissure systems (Frencken and Wolke, 2012)9, preventing stagnation of cariogenic plaque in difficult to clean deep pits and fissures due to the excellent adhesion of glass-ionomers to enamel and the fact that the material fractures in itself rather than at the enamel-sealant interface (Papacchini et al, 2005).10

It is concluded that the ART sealant is a very effective carious lesion preventive treatment both inside and outside the dental surgery.

ART restorations

Contemporary treatment of dentine cavities is based on removing decomposed (previously named ‘infected’) dentine, because it is useless, and leaving demineralised (previously named ‘affected’) dentine behind because it can remineralise (Frencken et al, 2012)1. The cleaned cavity is restored with a biocompatible material that has optimum physical properties. Removing decomposed dentine is most adequately achieved using a chemo-mechanical gel but this method takes a relatively long time. The next best effective method is through using a sharp metal hand excavator. The rotating metal dental drill, has a tendency to over prepare the cavity (Frencken et al, 2012)11.

How effective are ART restorations?

The first material used with the ART was polycarboxylate cement but it was soon followed by a medium-viscosity glass-ionomer cement in the late 1980-ties. Dental practitioners that wish to produce ART restorations that will survive long, should select high-viscosity glass-ionomers that have been tested favourably in clinical studies of long duration. But they should know the physical strength of the material. The latest development in this area shows that applying heat to setting high-viscosity glass-ionomers using a high intensity LED curing light, increased the materials’ biaxial flexural strengths substantially.12

Survival of ART restorations

The most recent meta-analyses on the performance of ART restorations, concluded5:

  • ART using high-viscosity glass-ionomer can safely be used in single-surface cavities in both primary and permanent posterior teeth;
  • ART using high-viscosity glass-ionomer cannot be routinely used in multiple-surface cavities in primary posterior teeth;
  • insufficient information is available for conclusions about ART restorations in multiple-surfaces in permanent posterior teeth, and in anterior teeth in both dentitions;

ART restorations versus traditional restorations

Systematic reviews and meta-analyses show that the longevity of ART restorations in primary teeth are not different from those produced in the traditional way using either amalgam (Mickenautsch et al. 2010; Mickenautsch and Yengopal, 2012)13,14 or resin composite (Raggio et al, 2012)15.

Similarly to the comparison between ART and conventional approaches in primary teeth, there appears to be no difference between the two approaches in the longevity of single-surfaces restorations in permanent dentition (Frencken et al, 2004; Mickenautsch 2012)16,14. Examples of ART restorations over time are presented in figures 2 and 3.

Dentine carious lesion development at the margin of ART glass-ionomer restorations was reported to be low  [Lo et al, 2007; Zanata et al, 2010; Taifour et al, 2002; Farag et al, 2009)17-20. This finding is supported by the results of the systematic review which showed that glass-ionomer had a higher caries-preventive effect than amalgam restorations in permanent teeth, with no difference in primary teeth (Mickenautsch and Yengopal, 2011)21.

Current evidence restricts the unconditional use of ART to the treatment of dentine cavities in single tooth surfaces.

Conclusion

The ART approach is very effective in preventing carious lesion development. ART sealants are as effective in preventing carious lesion development as resin-based sealants. The use of ART results in comparable smaller cavities and higher acceptance of preventive and restorative care by children. It can be unconditionally used to treat single-surface tooth cavities in primary and permanent teeth. Because no electricity and running water is required, ART restorations can be placed both in the field and in the private practice.

Acknowledgements

The contribution of many researchers to further ART for improving oral health of many is recognized and appreciated.

References

  1. Frencken JE, Pilot T, Songpaisan Y, Phantumvanit P. Atraumatic restorative treatment (ART): rationale, technique, and development. J Public Health Dent 1996: 56:135-140.
    1. Frencken JE, Makoni F, Sithole WD. ART restorations and glass ionomer sealants in Zimbabwe: survival after 3 years. Community Dent Oral Epidemiol 1998; 26: 372-381.
    2. van ‘t Hof MA, Frencken JE, van Palenstein Helderman WH, Holmgren CJ. The atraumatic restorative treatment (ART) approach for managing dental caries: a meta-analysis. Int Dent J 2006; 56: 345-351.
    3. De Amorim RG, Leal SC, Frencken JE. Survival of ART Sealants and ART restorations: A meta-analysis. Clin Oral Invest 2012; 16: 429-441.
    4. Beiruti N, Frencken JE, van ‘t Hof MA, van Palenstein Helderman WH. Caries preventive effect of resin-based and glass ionomer sealants over time: A systematic review. Community Dent Oral Epidemiol 2006; 34: 403-409.
    5. Yengopal V, Mickenautsch S, Bezerra AC, Leal SC. Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: a meta analysis. J Oral Sci 2009; 51: 373-382.
    6. Mickenautsch S, Yengopal V. Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: An update of systematic review evidence. BMC Res Notes 2011; 4: 22.
    7. Mickenautsch S, Yengopal V, Banerjee A. Atraumatic restorative treatment versus amalgam restoration longevity: a systematic review. Clin Oral Investig 2010; 14:233-240.
    8. Mickenautsch S, Yengopal V. Failure rate of atraumatic restorative treatment using high-viscosity glass-ionomer cement compared to that of conventional amalgam restorative treatment in primary and permanent teeth: a systematic review update. J Minim Interv Dent 2012; 5:63-124.
    9. Raggio DP, Hesse D, Lenzi TL, A B Guglielmi C, Braga MM. Is Atraumatic restorative treatment an option for restoring occlusoproximal caries lesions in primary teeth? A systematic review and meta-analysis. Int J Paediatr Dent 2012; Nov 28. doi: 10.1111/
    10. Frencken JE, van ’t Hof MA, van Amerongen WE, Holmgren CJ. Effectiveness of single-surface ART restorations in the permanent dentition: A meta-analysis. J Dent Res 2004; 83:120-123.
    11. Lo ECM, Holmgren CJ, Hu D, Wan H, van Palenstein Helderman W. Six-year follow-up of atraumatic restorative treatment restorations placed in Chinese school children. Community Dent Oral Epidemiol 2007; 35:387-392.
    12. Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF (2011) Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig 15:265-271.
    13. Taifour D, Frencken JE, Beiruti N, Van ‘t Hof MA, Truin GJ. Effectiveness of glass-ionomer (ART) and amalgam restorations in the deciduous dentition – results after 3 years. Caries Res 2002; 36:437-444.
    14. Farag A, van der Sanden WJM, Abdelwahab H, Mulder J, Frencken JE. 5-Year survival of ART restorations with and without cavity disinfection. J Dent 2009; 37:468-474.
    15. Mickenautsch S, Yengopal V. Absence of carious lesions at margins of glass-ionomer cement and amalgam restorations: An update of systematic review evidence. BMC Res Notes 2011; 11;4:58.
  1. Leal SC, De Menezes Abreu DM, Frencken JE. Dental anxiety and pain related to Atraumatic Restorative Treatment. J Appl Oral Sci 2009; 17:84-88.
  2. Frencken JE, Wolke J. Clinical and SEM assessment of ART high-viscosity glass-ionomer sealants after 8-13 years in 4 teeth. J Dent 2010; 38: 59-64.
  3. Papacchini F, Goracci C, Sadek FT, Monticelli F, Garcia-Godoy F, Ferrari M. Microtensile bond strength to ground enamel by glass-ionomers, resin-modified glass-ionomers, and resin composites used as pit and fissure sealants. J Dent 2005; 33: 459-467.
  4.  Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, Eden E. Minimal Intervention Dentistry (MID) for managing dental caries – a review. Int Dent J 2012; 62:223–243
  5. Molina GF, Cabral RJ, Mazzola I, Brain Lascano L, Frencken JE. Biaxial Flexural Strength of high-viscosity glass-ionomer cements heat-cured with an LED lamp during setting. BioMed Res Int 2013; in press.

  

Jo frencken
A
Jo frencken 2
B.
C.
C.

 

A.  Tooth 37 after 12 years and tooth 36 after 13 yrs (Fuji IX, hand-mixed). B. Same ART sealants 2.5 years later (Courtesy: J. Frencken).  C. Tooth 46 after 4 years (Ketac Molar, hand-mixed) (Courtesy: C. Holmgren).

Figure 1. ART sealants of long duration.

 

in #65 at baseline

Jo Frencken 2.1
Figure: 2.1

ODP ART restoration

Jo Frencken 2.2
Figure: 2.2

after 1 year

Jo Frencken 2.3
Figure: 2.3

after 2 years

 

Cavity occlusal #65

Jo Frencken 2.4
Figure: 2.4
Jo Frencken 2.5
Figure: 2.5

Cleaned cavity
using ART

Jo Frencken 2.6
Figure: 2.6

ART restoration
after 1 year

Jo Frencken 2.7
Figure: 2.7

after 2 years

Figure 2.  ART restorations using Ketac Molar Easymix after 2 years (Courtesy: S. Leal).

Jo Frencken 3.1
Figure: 3,1

ART restoration after 3 months

Jo Frencken 3.2
Figure: 3,2

ART restoration after 5 years

Jo Frencken 3.3
Figure:3,3

ART restoration at baseline

 

Jo Frencken 3.4
Figure: 3,4

ART restoration after 10 years

Figure 3.  ART restorations in occlusal surface after 5 years using Fuji IX capsules (Courtesy: A. Farag) and after 10 years using Fuji IX powder-liquid mixture (Courtesy: F. Navarro).