TN OT R IASTTI R VY E R E S T O R A T I V ER EDS E

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ART:A Minimal Intervention Approach to Manage Dental Caries

JO E. FRENCKEN AND CHRISTOPHER J. HOLMGREN
Abstract: The number of studies investigating aspects of the Atraumatic Restorative
Treatment (ART) approach has increased in recent years. This tissue preservative treatment approach appears to be less painful and is, therefore, more patient-friendly than conventional caries treatments. The investigations so far have shown that the ART approach is effective for the management of single-surface cavities in both deciduous and permanent dentitions. There appears to be no difference in survival results between single-surface ART restorations and comparable amalgam restorations in the permanent dentition after three years. The surface wear of ART restorations using high-viscosity glass-ionomers after two years is low. ART sealants using high-viscosity glass-ionomers are retained longer than ART sealants using low-viscosity glassionomers after three years. It is concluded that the ART approach is beneficial in improving the oral health of many, not only in developing but also in more advanced countries. Dent Update 2004; 31: 295301

Clinical Relevance: ART is a patient-friendly, preventive and restorative treatment

approach that has a place alongside traditional treatment approaches.

sealants. After cleaning the surface, highviscosity glass-ionomer is pressed into the pits and fissures with an index finger. Thus the ART approach consists of two components; a sealant-restoration and a preventive sealant. Research has shown that patients consider the ART approach less painful than the conventional approach.4,5 There is no noise from the drill and the suction, and local anaesthesia is hardly ever required. More detailed information on the approach is given in the ART book.6 The first results of studies evaluating the ART approach were published some 10 years ago. The number of studies has increased in recent years. This paper aims to provide a short overview of the published results on the survival of ART restorations and ART sealants up until the end of December 2002.

traumatic Restorative Treatment (ART) takes a special place within the group of minimal intervention approaches for the management of dental caries.1 The operative procedures have previously been described in this journal2 but, in brief, only soft, infected dentine is removed using hand instruments (Figure 1). This makes it possible to keep the resultant cavities

Jo E. Frencken, BDS, MSc, PhD, Associate Professor in Preventive Dentistry,WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios and Christopher J. Holmgren, BDS, PhD, Visiting Professor in Preventive and Community Dentistry, WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios, University of Nijmegen, the Netherlands.

smaller than would be achieved using a drill.3 The cleaned cavity and adjacent pits and fissures are then filled with an adhesive restorative material. The resulting sealant-restoration is thus both preventive and restorative. Most studies that have investigated the ART approach have used glass-ionomers as the filling material. The studies carried out before 1994 used a low-viscosity glass-ionomer, whereas the latter studies used a high-viscosity glass-ionomer. ART studies are currently underway using composite and compomer. Because of its chemical adhesion to enamel and its improved physical properties, high-viscosity glassionomers can also be used to seal pits and fissures in the absence of cavitation. These are called ART

SURVIVAL OF ART RESTORATIONS IN THE DECIDUOUS DENTITION Single-surface Restorations

Most of the survival studies referred to in this review used the same ART criteria.6,7 Three studies have been published thus far.7-9 Only two studies have reported results of three years (Table 1). In the most recently published study, eight dentists treated children with an average age of 7.5 years.8 The three-year survival percentage was 86%. Secondary caries was observed in only 1% of the restorations placed. The China-study was carried out among 3 to 6-year-old children and revealed a
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e Figure 1. Some operational procedures to produce an ART restoration: (a) cavitated dentinal lesion; (b) opening with hand instrument; (c) cleaned cavity; (d) filling cavity and pits and fissures; (e) sealant restoration.

survival percentage of 79% for Class I restorations after 30 months.7 This study indicates a use for ART in young children. Because of the low number of studies, it is not possible to draw a firm conclusion but the results thus far are promising.

multiple-surface ART restorations was too low for analyses.

Single-surface Restorations
The technique to produce ART restorations is improving continuously.
Age Number Survival last (%) in years evaluation 1 2 65 320 53 91 95 94 79* 91 92 86

Country

Period

Operator Material

China 7

1996-98 1997-00 1997-99

D stud D D

Ketac-Molar Fuji IX Ketac-Molar ChemFlex Fuji IX GP

36 68 614

Multiple-surface Restorations
Five studies have been published of which only one is of three years duration (Table 2). This 3-year study showed that about half of the multiplesurface ART restorations failed technically.8 This finding is similar to that for other approaches and other restorative materials where multiplesurface restorations survive for a shorter period than single-surface restorations. There is insufficient information to date to draw firm conclusions about the outcome of multiple-surface ART restorations in the deciduous dentition over a longer period since the number of studies is limited.

Syria8 China 9 D D stud *

Dentist Final year dental students Survival result after 30 months

Table 1. Overview of survival results of single-surface ART restorations in deciduous dentitions per study year.
Country Period Operator Material Age Number Survival last (%) in years evaluation 1 2 138 28 324 26 35 55 75 72 54 65 51* 60 43 49

Thailand China 7 Syria

8

10

199194 199698 199700 199799

D, DTh D stud D D D

ChemFil KetacMolar Fuji IX KetacMolar ChemFlex Fuji IX GP Fuji IX GP KetacMolar

68 36 68 614 79

China 9

SURVIVAL OF ART RESTORATIONS IN THE PERMANENT DENTITION

Most of the ART studies have reported survival results of single-surface restorations up to 3 years (Figure 2).2,12-19 In most of these studies, the number of
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China11 D DTh D stud *

Dentist Dental therapist Final year dental students Survival result after 30 months

Table 2. Overview of survival results of multiple-surface ART restorations in the deciduous dentition. Dental Update June 2004

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conventionally produced restorations.

100
China (1996-01)

Permanent Dentition
China (1997-99) Hong Kong (1995-97)

90 80 % 70 60 0 1 2 3 Year 4 5

Pakistan (1995-97) Syria (1998-01) Tanzania (1992-94) Thailand (1991-94) Zimbabwe (1993-96) Zimbabwe (1994-97)

Figure 2. Overview of survival results of single-surface ART restorations in permanent dentitions per study year.

For ART in the permanent dentition there is a total of five publications with a maximum duration of three years (Table 4). All studies reported on the survival of single-surface restorations. There was no statistically significant difference between the two approaches in four of the five studies. Only the Thailand-study showed a statistically significant difference: amalgam restorations survived longer. The latter was the study that used a low-viscosity glass-ionomer and in which the operators were still investigating the technique of cleaning cavities using hand instruments. It looks somewhat premature to draw a conclusion, but the available data seem to indicate that there is no difference in survival of singlesurface ART and amalgam restorations after three years.

In the earlier studies, low-viscosity glass-ionomers were used and the method used to clean tooth cavities was investigated.16,17 These two characteristics have been mentioned as reasons for the lower survival results observed in the earlier compared to the latter ART studies. The fact that the survival results of the group of latter studies show little difference indicates that the overall finding is very robust. It can be concluded therefore that about 45% of single-surface ART restorations using high-viscosity glass-ionomers fail technically annually within the first three years after placement. The proportion of secondary caries as a failure in the ART restoration is very low; 1.52.5%.18,19

the number of such studies remains low. The Syria-study showed that single-surface ART restorations survived longer than comparable amalgam restorations after three years.8 The study comparing ART with compomer restorations is still of short duration. There was no difference between both methods after one year.20 It seems obvious that more studies are required to arrive at a well founded conclusion with respect to the effectiveness of ART restorations in the deciduous dentition compared to

SURFACE WEAR OF ART RESTORATIONS

There are two publications reporting on the surface wear of single-surface ART restorations (Table 5). It is known that the setting reaction of glass-ionomers is time related and that the material has reached its hardness only after months. During this period, and in particular during the first couple of days, the material is prone to surface wear. It is known that the surface wear of highviscosity glass-ionomers is less than that of low-viscosity glass-ionomers.22 A

Country

Number at last evaluation A/G C/A 32 285

Survival (%) ART/GIC(years) 1 93 95 2 91 3 86

Survival (%) Conventional/ Amalgam (years) 1 100 93 2 87 3 80 n.s s.s

COMPARISON OF ART WITH CONVENTIONAL TREATMENT Deciduous Dentition

ART restorations have been compared with amalgam restorations (Table 3) but
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China Syria8

11

37 320

n.s not statistically significant s.s statistically significant

Table 3. Survival percentages of single-surface restorations in the deciduous dentition produced through the ART approach using glass-ionomer (A/G) and the conventional approach using amalgam (C/A). 297

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Country

Survival (%) ART/GIC (years) 1 2 83 93 94 87 3 71 81 82

Survival (%) Conventional/Amalgam (years) 1 98 99 97 89 2 94 94 88 81 3 85 90 77 Difference s.s n.s n.s n.s n.s

Thailand 16 Malawi21 Tanzania 15 Pakistan2 Syria14

93 96 98 93

n.s not statistically significant s.s statistically significant

molars was investigated in a pilot study.28 Compared to unsealed control molars, the pits and fissures of the sealed newly erupted first molars had a near to 50% lower chance of developing a dentinal lesion after five years. Although sufficient evidence is lacking at the moment, it is not unrealistic to expect that high-viscosity glass-ionomer ART sealants will ultimately be shown to be a reliable caries preventive method, particularly for use in deep pits and fissures in caries high-risk populations.

Table 4. Difference in survival percentages of single-surface restorations in the deciduous dentition produced through the ART approach using glass-ionomer (A/G) and the conventional approach using amalgam (C/A).
Deciduous dentition China
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CONCLUSIONS
Over the last decade, results from research from numerous countries have shown the considerable strengths and some of the limitations of the ART approach. We know for certain that the ART approach is very patient-friendly and that it produces good short-term survival results for the treatment of single-surface dentinal lesions in both deciduous and permanent dentitions. Additional research is, however, required with respect to its use in multisurface cavities and for when other adhesive restorative materials are used. Experience from applying ART in dental practices shows that children, in particular, seem to benefit from this treatment approach. This applies not only to children living in less industrialized, but also to those who live in industrialized, countries. It is an excellent introduction to dental care and can help to overcome the fears of traditional care using a drill and local anaesthetic. In this respect, it also has a place for the treatment of nervous patients who would otherwise not accept dental treatment. Recently, results of a study about the use of ART amongst senior citizens were published.29 The authors considered that ART is a suitable approach to bring oral healthcare to home-bound senior citizens. In conclusion, research has shown that the ART approach contributes to the improvement of oral health for many the world over and should form an essential part of every dentists armamentarium.
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Material ChemFlex Fuji IX GP Material ChemFil Superior Fuji IX ChemFlex Fuji IX GP

Surface wear 87 microns 85 microns Surface wear 104 microns 83 microns 75 microns 79 microns

Permanent dentition Hong Kong13 China 9

Table 5. Mean cumulative surface wear of single-surface ART restorations using glass-ionomer in the deciduous and permanent dentitions after 2 years.

recent in vitro study showed that there was no statistically significant difference in surface wear between glass-ionomers, composite resin and amalgam if subjected to toothbrushing.23 The level of surface wear reported in the two ART studies are in line with results reported for occlusal wear of a large number of composite resins.24 Because of the different measurement instruments used in the two referred studies, it is difficult to draw firm conclusions from these studies, but they do show that the surface wear of modern high-viscosity glass-ionomer has improved.

GLASS-IONOMER ART SEALANTS

Pit and fissure sealants are placed to prevent caries development. In measuring its success, the level of sealant retention must, therefore, be
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considered a surrogate end-point where the development of caries would be a true end-point. Although composite resin sealants show a higher retention rate than (low-viscosity) glass-ionomer, there is no clear evidence that composite resin sealants are superior in preventing caries than glass-ionomer sealants.25 The retention of high-viscosity glassionomer sealants (ART sealants) is higher than that of type III (lowviscosity) glass-ionomer sealants.26 After three years, about 70% of highviscosity glass-ionomer ART sealants were fully and partially retained in caries high-risk pits and fissures (Table 6). Caries developed in only 24% of sealed surfaces in the studied groups of adolescents.18,19 Comparative studies between high-viscosity glass-ionomer and composite resin sealants have not been published. Recently, the caries preventive effect of high-viscosity glass-ionomer in newly erupted first

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Country

Period

Operator Material

Age

Number at last evaluation 107

Survival (%) (year) 1 2 3

Thailand*27 Zimbabwe*17 Zimbabwe**

18

199194 199396 199497 199597

D, DTh D, DTh D, DTh D

ChemFil ChemFil Superior Fuji IX

758

78 64 50 75 63 50 90 86 71

1316 314 1316 6 6

Hong Kong13

ChemFil Superior Fuji IX 12 KetacMolar 1 2

87 130

82 66

China** 12

199601

DTh

90 79 71 68 63

D Dentist DTh Dental therapist * Sealants were placed in pits and fissures with early enamel lesions. ** Sealants were placed in deep pits and fissures with early enamel lesions (caries high risk group).

Table 6. Overview of survival percentages of fully and partially retained ART sealants in the permanent dentition.

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11. Yip HK, Smales RJ, Yu C, Deng DM. Comparison of Atraumatic Restorative Treatment and conventional cavity preparations for glassionomer restorations in primary molars: oneyear results. Quintessence Int 2002; 33: 1721. 12. Holmgren CJ, Lo ECM, Wan HC, Hu DY. ART restorations and sealants in Chinese school children five year results. J Dent Res 2000; 79: 204. 13. Ho TFT, Smales RJ, Fang DKS. A 2-year clinical study of two glass ionomer cements used in the atraumatic restorative treatment (ART) technique. Community Dent Oral Epidemiol 1999; 27: 195201. 14. Taifour D, Frencken JE, Beiruti N, Van t Hof MA, Truin GJ,Van Palenstein Helderman WH. Comparison between restorations in the permanent dentition produced by hand and rotary instrumentation survival after 3 years. Community Dent Oral Epidemiol 2003; 31: 122 128. 15. Mandari GJ, Truin GJ, vant Hof MA, Frencken JE. Effectiveness of three minimal intervention approaches for managing dental caries: Survival of restorations after 2 years. Caries Res 2001; 35: 9094. 16. Phantumvanit P, Songpaisan Y, Pilot T, Frencken JE. Atraumatic Restorative Treatment (ART): survival of one-surface restorations in the permanent dentition. J Public Health Dent 1996; 56: 141145. 17. Frencken JE, Makoni F, Sithole WD, Hackenitz E. Three-year survival of one-surface ART restorations and glass-ionomer sealants in a school oral health programme in Zimbabwe. Caries Res 1998a; 32: 119126. 18. Frencken JE, Makoni F, Sithole WD. ART restorations and glass ionomer sealants in Zimbabwe: survival after 3 years. Community Dent Oral Epidemiol 1998b; 26: 372381. 19. Holmgren CJ, Lo ECM, Hu DY, Wan HC. ART restorations and sealants placed in Chinese school children results after three years. Community Dent Oral Epidemiol 2000; 28: 314

320. 20. Louw AJ, Sarvan I, Chikte UME, Honkala E. Oneyear evaluation of atraumatic restorative treatment and minimal intervention techniques on primary teeth. S Afr Dent J 2002; 57: 366371. 21. Kalf-Scholte SM, van Amerongen WE, Smith AJE, van Haastrecht HJA.Atraumatic Restorative Treatment (ART): a three-year clinical study in Malawi comparison of conventional amalgam and ART restorations. J Public Health Dent 2003; 63: 99103 22. Yip HK, Smales RJ, Ngo HC, Tay FR, Chu FCS. Selection of restorative materials for the atraumatic restorative treatment (ART) approach: a review. Spec Care Dentist 2001; 21: 216221. 23. McCabe JF, Molyvda S, Rolland SL, Rusby S, Carrick TE. Two- and three-body wear of dental restorative materials. Int Dent J 2002; 52: 406 416. 24. Sderholm KJM, Lambrechts P, Sarrett D et al. Clinical wear performance of eight experimental dental composites over three years determined by two measuring methods. Eur J Oral Sci 2001; 109: 273281. 25. Simonsen RJ. Glass ionomer as fissure sealant a critical review. J Public Health Dent 1996; 56: 146149. 26. Weerheijm KL, Kreulen CM, Gruythuisen RJ. Comparison of retentative qualities of two glassionomer cements used as fissure sealants. J Dent Child 1996; 63: 265267. 27. Phantumvanit P, SongpaisanY, Frencken JE, Pilot T. Survival of ART sealants in 3-year community field trial. J Dent Res 1998; 77: 972. 28. Taifour D, Frencken JE, van t Hof MA, Beiruti N, Truin GJ. Effects of glass ionomer sealants in newly erupted first molars after 5 years: A pilot study. Community Dent Oral Epidemiol 2003; 31: 122128. 29. Honkala S, Honkala E. Atraumatic dental treatment among Finnish elderly persons. J Oral Rehab 2002; 29: 435440.

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