d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 16

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/dema

The ART approach using glass-ionomers in relation to

global oral health care
Jo E. Frencken
Department of Global Oral Health, Radboud University Nijmegen Medical Centre, College of Dental Sciences, P.O. Box 9101, 6500 HB
Nijmegen, Nijmegen, The Netherlands

a r t i c l e

i n f o

a b s t r a c t

Article history:

Dental caries is the most prevalent non-communicable disease in the world. Its manage-

Received 13 November 2008

ment in high-income countries over the last four decades has resulted in relatively low caries

Accepted 21 August 2009

prevalence in child and adolescent populations. In low- and middle-income countries, caries
management is virtually non-existent and this may lead to serious physical and mental
complications, particularly in children. Toothache is predominantly treated by extracting

Keywords:

the cavitated tooth. Absence of restorative oral care is partly due to the copying from high-

Glass-ionomer

income countries, of restorative treatment reliant on electrically driven equipment and often

Atraumatic Restorative Treatment

inappropriate for use in many low- and middle-income countries. Atraumatic Restorative

Developing countries

Treatment (ART), which does not rely on electrically driven equipment, has yielded good

Oral healthcare services

results over the last two decades. ART uses hand instruments and high-viscosity glass-

Untreated cavities

ionomers. Its introduction into public oral healthcare systems has been piloted in several

Dental caries

countries. Initial short-term results show that the introduction of ART, using high-viscosity
glass-ionomers, has increased the ratio of restorations to extractions. Moreover, the percentage of ART restorations in relation to the total number of restorations placed increased
steeply after its introduction and has remained high. However, ART introduction faced a
few barriers, the most important being high patient workloads and the absence of a constant supply of dental instruments and glass-ionomers. High-viscosity glass-ionomer has
become an essential element in public oral healthcare systems, particularly in those operating inadequately.
2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

1.

Introduction

Dental caries is the most prevalent non-communicable disease in the world. Its distribution among children, however,
is skewed. Caries prevalence is relatively low in high-income,
and relatively high in low- and middle-income countries. Children from high-income countries have beneted from the
available established caries preventive measures; such as the
use of uoride-containing products and awareness among

their parents and caretakers of the importance of keeping

tooth surfaces free from plaque. In addition, children who
have developed tooth cavities can utilize the well-organized
oral healthcare services operating in many high-income countries. Children, adolescents and adults in these countries can
comfortably rely, for oral care, on the available healthcare systems, often nanced by government and/or private insurance
schemes.
The oral healthcare situation for people in low- and middleincome countries is completely different. Not only is the

Tel.: +31 24 361 4050; fax: +31 24 354 0265.

E-mail address: j.frencken@dent.umcn.nl.
0109-5641/$ see front matter 2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2009.08.013

d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 16

prevalence of dental caries higher and its severity greater;

the oral healthcare system is usually insufciently equipped
to provide the needed care. This means that many in these
countries suffer in many ways: most carious cavities are not
treated restoratively. People with open cavities usually present
themselves at a health center or dental clinic when pain
is unbearable. Extracting the badly decayed tooth is then
the treatment of choice but the prevalent unavailability of
restorative care can have serious consequences, especially for
children. A study from the Philippines revealed that almost
all carious cavities in 6- and 12-year-olds remained untreated
and that 40% of these cavities were accompanied by infection
of the pulp, abscesses, stulas and/or infected root remnants
[1]. These conditions may pose a serious threat to childrens
general health, because of the risk of developing systemic
sepsis, osteomyelitis and infection of the neck and the oor
of the mouth. Furthermore, toothache may alter childrens
eating and sleeping habits which can affect their growth negatively [2]. Untreated carious cavities in children have also been
associated with protein-energy malnutrition [3,4] and stunted
growth [5], and children suffering from early childhood caries
have been associated with lower body weight and reduced
body length [6].
Untreated carious cavities do not only have an impact
on the physical condition of children; but their cognitive
development may also become impaired. In a survey of
native-American schoolchildren, one third admitted to missing school because of dental pain [7], and 70% of children in
the Western Cape, South Africa, had missed school due to
toothache [8]. The seriousness of the absence, or low coverage, of oral (restorative) care in many low- and middle-income
countries is demonstrated in the case of the Philippines. The
countrys Department of Education reported toothache as the
principal reason for absenteeism from schools [9]. The effect of
chronic dental pain in children is not a supposition: affected
children are unable to focus and unable to complete school
assignments, which affects their school performance negatively [10].
So, why do people in low- and middle-income countries not
receive sufciently organized restorative oral care?

2.

Restorative oral care

In high-income countries, restorative oral care relies on electrically driven equipment and a well-functioning piped water
system. The care is provided in a dental clinic building by
dental professionals who are generally well paid. Of late,
globalization has encouraged dental professionals to travel,
mainly for holidays, to low- and middle-income countries.
However, a growing number undertake the travel to provide
oral care to those in need. The latter group will have encountered an oral healthcare system that is completely different
from those that they are used to. Dental clinics with equipment that is non-functional because of a lack of spare parts,
unavailability or irregularly of electricity supply and piped
water and a shortage of materials and instruments are more
the rule than the exception in many low- and middle-income
countries. Provision of oral care in these countries is, therefore,
poorly developed and covers a small part of the population;

mainly those residing in cities. Most of these dental clinics

have been equipped as copies of those in high-income nations.
This is a perfect example of a transfer of systems without
adaptation: as if cultural differences do not exist and as if
countries are organized and run in one identical way.
But what kind of restorative oral care could make the difference?

3.

Atraumatic Restorative Treatment (ART)

Over the last two decades a preventive and restorative

caries management concept has been developed: Atraumatic
Restorative Treatment (ART). ART does not require electricity
or piped water systems. It uses hand instruments for opening
and cleaning tooth cavities and mainly uses a glass-ionomer to
ll the cleaned cavities and to seal caries-prone tooth surfaces
[11]. Autocure glass-ionomers are essential in this context as
their powder-liquid hand-mixed form is appropriate everywhere in the world. Other restorative materials require, in one
way or another, the use of electricity-driven equipment. The
combined use of hand instruments and glass-ionomers, therefore, make it possible to improve the oral health well-being of
population groups in many countries.
The poorly equipped state of dental clinics in many lowand middle-income countries restricts oral healthcare provision in the areas that they serve. Restriction is demonstrated
by dentists only extracting teeth, day in and day out. For
example, the restoration/extraction ratio in South Africas
public oral healthcare system is 0.11 [12], which is similar
to that of Tanzania (0.04) [13], indicating that dental personnel rarely restore teeth, usually extracting them instead. The
introduction of ART into the oral healthcare systems of these
countries would facilitate a reduction in tooth extractions
and an increase in the proportion of teeth that are instead
restored and sealed. It would also increase the quality of life
of many and the job satisfaction of dentists. It is obvious
that the introduction of ART, using glass-ionomers, is alone
insufcient to improve the oral health of people in low- and
middle-income countries in a sustainable manner. Therefore,
the WHO Collaborating Centre of Oral Health Care Planning
and Future Scenarios in Nijmegen, the Netherlands, has developed a package of pain relief and preventive, promotional
and restorative evidence-based treatments for use in low- and
middle-income countries in 2002: the Basic Package of Oral
Care (BPOC) [14], which includes ART. Nevertheless, how good
is ART?

4.

Results of investigations on ART

Many researchers from many countries have investigated different aspects of ART. Salient ndings from these studies can
be summarized as follows:

- Survival rates of single-surface ART restorations using

high-viscosity glass-ionomers in primary and permanent
posterior teeth are high and meet the specications of the
American Dental Association (ADA) [15].

d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 16

- Survival rates of multiple-surface ART restorations using

high-viscosity glass-ionomers in primary posterior teeth do
not meet the ADA specications [15].
- Survival rates of single-surface ART restorations in permanent posterior teeth, using high-viscosity glass-ionomers,
do not differ signicantly from comparable traditional
restorations using amalgam [16,17].
- Survival rates of single-and multiple-surface ART restorations, using high-viscosity glass-ionomers, in primary
posterior teeth do not differ signicantly from comparable
traditional restorations using composite [18,19] and compomer [20].
- The caries preventive effect of ART sealants using
high-viscosity glass-ionomer is very high [15] and was
signicantly higher than that of sealants produced using
composite resin [21].
- Pain felt during treatment was lower in child populations
treated restoratively with ART using high-viscosity glassionomers, than when traditional restorative procedures
were used [2224]. Even ART without local anesthesia was
better accepted than traditional treatment with local anesthesia [25].
- Dental anxiety in adults treated using ART in public health
clinics was lower than when adults were treated using traditional restorative procedures [26]. This difference between
the two types of treatment was not observed in children
treated in a modern dental clinic [27].
- Initial wear rates of ART restorations using high-viscosity
glass-ionomers are low [28,29].
- ART restorations using high-viscosity glass-ionomers were
more cost-effective after 2 years than comparable amalgam
restorations [30].
These outcomes show that the ART approach using
high-viscosity glass-ionomers produces quality sealants, and
restorations in single-surface cavities in primary and permanent posterior teeth.

5.

ART and glass-ionomers

The rst material used in conjunction with the ART approach

was a carboxylate cement. This material was soon replaced
by a medium-viscosity glass-ionomer in the late eighties.
At that time, medium-viscosity glass-ionomers were mainly
used for lling cavities in non-stress-bearing situations such
as in buccal surfaces, where they survived for long [31]. Given
the circumstances in which cavitated teeth were routinely
extracted to alleviate pain, lling a hand instrumentscleaned cavity in a stress-bearing surface (occlusal) with a
medium-viscosity glass-ionomer was considered acceptable.
It was soon realized that restorations using this type of
glass-ionomer performed better than expected [32,33]. This
observation prompted manufacturers to improve the physical characteristics of autocure glass-ionomers, resulting in
the marketing of high-viscosity glass-ionomers. The metaanalysis on the effectiveness of ART restorations has shown
that single-surface ART restorations using high-viscosity
glass-ionomer survived signicantly longer than comparable
restorations using medium-viscosity glass-ionomers [15]. This

implies that medium-viscosity glass-ionomers should not be

used with ART in practice.
Not only has the survival of ART sealants and ART
restorations using glass-ionomers been investigated: various
properties of high-viscosity glass-ionomers have also been
researched for use in combination with ART. The pressnger technique, of pressing the glass-ionomer with an index
nger in pits and ssures, appears to be functioning well.
The ssure penetration depth of high-viscosity glass-ionomer
sealants, placed using the press-nger technique, did not differ signicantly from that of composite resin sealants [34].
There was also no difference in ssure penetration depth
between high-viscosity glass-ionomer sealants placed using
the press-nger technique and a ball-burnisher [21]. Some
studies have reported lower bond strength between tooth tissues and high-viscosity glass-ionomers than was achieved
for resin-modied glass-ionomer used in ART restorations
[35,36]. However, no signicant difference in quality of bonding
was observed at the interface between high-viscosity glassionomers and enamel and dentin prepared using ART and
conventional rotary instruments [37]. Furthermore, microscopic observations showed that voids and bubbles are present
in high-viscosity glass-ionomer ART restorations [38] and that
the inuence of the press-nger technique appears to have little or no effect in spreading the high-viscosity glass-ionomer
into the tooth cavity [39]. The outer surface of ART glassionomer restorations has also been investigated. The level
of surface roughness of two high-viscosity glass-ionomers
was lower than the critical surface roughness of 0.2 m.
The antibacterial activity of high-viscosity glass-ionomers
used with ART has recently been investigated. Both freshly
mixed [40,41] and 1-week-old high-viscosity glass-ionomers
[41] showed antibacterial properties against various microorganisms.
Although glass-ionomers have a number of benecial properties, these may not always be sufcient for their use in
certain restorative situations. Nevertheless, glass-ionomers
have earned their place in restorative dentistry in low-, and
middle-, and high-income countries, and certainly in combination with the ART approach. However, in order to produce
reliable and long-lasting ART restorations, the dental practitioner needs to have acquired skills and comprehension and
to exercise diligence [38]. Therefore, following an ART training
course is essential.

6.
Introduction of ART and glass-ionomer
in oral health service systems
Researching ART and glass-ionomers over the last two decades
was necessary, to understand the potential and limits of the
individual components and their combination. Considering
the positive outcomes of the various meta-analyses on ART
restorations [15,16], individual studies and the systematic
review of the respective effectiveness of carious lesion prevention of glass-ionomer and composite resin sealants [42], a need
arose to introduce ART into oral health care service systems.
In the USA, ART appeared to be (very) often applied by 44%
of dental practitioners, mainly to treat children restoratively
[43]. The percentage of dentists using ART in the Netherlands

d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 16

was somewhat lower (26%). They used it to treat children and

anxious and handicapped adults [44]. In the United Kingdom,
ART is reported by some 10% of respondents, to have been
used mainly for children by the year 2002 [45].
Many dental practitioners in many low-and middle-income
countries are using ART; for example, between 2002 and 2007,
the Dental Department in the Ministry of Health of Mexico trained over 1000 dentists in ART and caries prevention.
This activity appears to have resulted in a 44% increase in
restorations provided through the public oral health services
in 2007, compared to 2002, which was, predominantly, a result
of the increase in number of ART restorations. In 2007, true
ART restorations accounted for 8% of the total number of
restorations placed, whereas 23% of these were ascribed to
restorations that may have been produced with some aid
of the drill in combination with hand instruments and a
high-viscosity glass-ionomer [personal communication]. Evaluation of further aspects of the introduction of the ART
approach in Mexico is underway.
It will be no surprise to many that introducing a novel treatment concept may not be a smooth undertaking. At the turn of
the century, when it became clear that the ART approach was
no ephemeron, (oral) health authorities in a province in South
Africa decided to incorporate ART into the provincial public
health services, as the level of restorative care had been low
for many years. All the 21 dentists in two regions followed a
3-day ART training course, after which they were requested
to treat patients restoratively using ART. No further support
was provided. The recorded clinical procedures of 11 of the 21
dentists were available from the beginning until 5 years after
the ART training [46]. Analysis showed that the mean restoration to extraction ratio (REX) had not signicantly increased.
This indicated that for these dentists extraction had remained
the predominant mode of treating cavitated dentin lesions
over the 5-year period. However, some positive inuences of
the ART introduction were noticed. Of the total number of
restorations placed in primary teeth, the proportion of ART
restorations increased from zero to 81% at year 1 and remained
high during the following 4 years (73% at year 5 after training).
Of the total number of restorations in permanent teeth, the
mean percentage of ART restorations increased signicantly
from zero to 24% at year 1 and to 43% at year 5. Unfortunately,
the number of restorations placed per year by these dentists
was low.
So, why did the number of restorations remain low? Factors that may have inuenced the utilization of ART were
investigated 1 year after the ART training [47]. It was concluded that an inadequate supply of dental materials inhibited
the provision of restorative care through ART instead of tooth
extractions for both adult and child patients. Furthermore, it
was found that dentists perceptions of low levels of clinical
skills in performing ART condently after training constituted
a barrier to utilising ART in children, but not in adults. High
patient load/work load, negative operator and patient opinion, insufcient chair-side assistance and poor management
of services by health authorities were other factors that inhibited the proper utilization of ART for adults in the public oral
health service 1 year after ART training. It was not just one
factor that hindered a proper adoption of ART by these dentists but the unavailability of sufcient dental instruments and

Fig. 1 Treatment pattern in one pilot clinic during the

follow-up period.
Key: - Dotted line denotes number of ART restorations
rendered during the follow-up period whose scale is on the
left side of the graph.
- Continuous line denotes the number of extractions
rendered during the follow-up period whose scale is on the
right side of the graph,
- ART training course was conducted in July 2005, and
practitioners were supplied with glass-ionomer cement
and ART hand instruments. Between July 2006 and April
2007, no glass-ionomer cement was supplied to this clinic.

glass-ionomers to produce ART restorations was considered a

major hindrance in restoring cavitated teeth.
Lessons learnt from South Africa were utilized in Tanzania. Before public dental personnel were trained in ART and
caries prevention, investigations into potential barriers causing the lack of restorative care in the public oral health services
were carried out among patients [48] and public dental personnel [49]. In addition, dental practitioners were interviewed
about their attitudes and intentions regarding use of the ART
approach [50]. The ndings of these studies were discussed
with the participating dental personnel during the rst days of
the ART course. The main perceived barriers to ART utilization
in Tanzania were the non-communication about restorative
care as an option for treating toothache between dental practitioners and the public [48,49], and the absence of suitable
hand instruments and glass-ionomer [51]. These essential
medical items have to be purchased by tender through the
government-owned Medical Stores. The importance of glassionomer is shown in the clinic statistics recorded during the
31-months following ART training. Data from 13 dental clinics reveal that the percentage of ART restorations in relation
to the total number of restorations increased immediately
after dental practitioners had returned to their clinics with a
starter pack of hand instruments and glass-ionomer. A couple
of months later, after the glass-ionomer supplies had been nished and no replacement glass-ionomer could be purchased
through Central Medical Stores, as this organization had not
succeeded in getting the tender organized, the number of
ART restorations dropped (Fig. 1). About a year later, after a
donation of glass-ionomer and the successful completion of
the glass-ionomer purchasing tender procedure, the number

d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 16

Fig. 2 Effectiveness of introduction of ART restorations in treatment proles of 13 government dental clinics in Tanzania
(20042008). Pre-ART training (011-months); post-ART training (1243-months to follow up).

of ART restorations rose again [13]. This observation shows

the importance of glass-ionomer, not only for the production of ART restorations but also for pain relief in populations
unaccustomed to receiving any restorative care. During the
31-month period following the ART course, ART restorations
using glass-ionomers accounted for between 3% and 14% of
the total number of procedures in these 13 public dental clinics (Fig. 2). The percentage of ART restorations relative to the
total number of restorations placed, at the 31-month period
after ART training, was 89% [13]. Many of the teeth treated by
ART during this follow-up period would have been extracted
had the approach not been introduced to the resident dentists
and dental therapists.

7.

Conclusion

Although the denition of the Atraumatic Restorative

Treatment approach includes the combined use of hand
instruments, adhesive systems and adhesive materials, in
practice high-viscosity glass-ionomers have turned out to be
the adhesive material mainly used. The hand-mixed version
allows worldwide ART sealant production and ART restorations in all population groups outside the dental clinics.
High-viscosity glass-ionomer is an essential element in oral
healthcare systems, particularly in those that are operating
inadequately. Information about its characteristics and handling ability, therefore, needs to be an integral part of the
ART training course. Together with hand instruments, highviscosity glass-ionomers need to be readily available at the
time when the ART approach is introduced into an oral health
care system.

references

[1] Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van

Palenstein Helderman W. PUFAAn index of clinical
consequences of untreated dental caries. Community Dent
Oral Epidemiol 2009, in press.

[2] Miller E, Vaughan-Williams R, Furlong R, Harrison L. Dental

caries and childrens weights. J Epidemiol Community
Health 1982;36:4952.
[3] Alvarez JO. Nutrition, tooth development and dental caries.
Am J Clin Nutr 1995;61:4106.
[4] Psoter WJ, Reid BC, Katz RV. Malnutrition and dental caries:
a review of the literature. Caries Res 2005;39:
4417.
[5] Alvarez JO, Lewis CA, Saman C, et al. Chronic malnutrition
dental caries, and tooth exfoliation in Peruvian children
aged 39 years. Am J Clin Nutr 1988;48:36872.
[6] Ayhan H, Suskan E, Yildirim S. The effect of nursing or
rampant caries on height, body weight and head
circumference. J Clin Pediatr Dent 1996;20:
20912.
[7] Chen MS, Andersen RM, Barmes DE, Leclercq MH, Lyttle CS.
Comparing oral health care systems: a second international
collaborative study. Geneva: World Health Organization;
1997.
[8] Naidoo S, Chikte UME, Sheiham A. Prevalence and impact of
pain in 8 year olds in the Western Cape. S Afr Dent J
2001;56:7015.
[9] Araojo JR. Philippine Country Report on School Health
Promotion Programme. In: 2nd Asian conference on oral
health promotion for school children, prospectus for our
future generation. Ayyuthaya, Thailand: Thammasat
University; 2003. p. 10310.
[10] Schechter N. The impact of acute and chronic dental pain on
child development. J Southeastern Soc Pediatric Dent
2000;6:16.
[11] Frencken JE, Pilot T, Sangpaisan Y, Phantumvanit P.
Atraumatic Restorative Treatment (ART): rationale,
technique, and development. J Public Health Dent
1996;56:13540.
[12] Gugushe T. Compulsory community service audit for
dentists in South Africa. Department of Community
Dentistry, Medical University of Southern Africa; 1998.
[13] Kikwilu EN, Frencken JE, Mulder J. The Impact of the
Atraumatic Restorative Treatment (ART) on the Treatment
Prole in Government Dental Clinics in Tanzania. BMC Oral
Health 2009;9:14.
[14] Frencken JE, Holmgren CJ, van Palenstein Helderman WH.
Basic package of oral care. Nijmegen: WHO Collaborating
Centre for Oral Health Care Planning and Future Scenarios;
2002.

d e n t a l m a t e r i a l s 2 6 ( 2 0 1 0 ) 16

[15] vant Hof MA, Frencken JE, van Palenstein Helderman WH,
Holmgren CJ. The ART approach for managing dental caries:
A meta-analysis. Int Dent J 2006;56:34551.
[16] Frencken JE, vant Hof MA, van Amerongen WE, Holmgren
CJ. Effectiveness of single-surface ART restorations in the
permanent dentition: a meta-analysis. J Dent Res
2004;83:1203.
[17] Frencken JE, Taifour D, vant Hof MA. Survival of ART and
amalgam restorations in permanent teeth after 6.3 years. J
Dent Res 2006;85:6226.
[18] Eden E, Topaloglu-Ak A, Frencken JE, vant Hof MA. Two-year
survival of composite ART and traditional restorations. Am J
Dent 2006;19:35963.
[19] Ersin NK, Candan U, Aykut A, Oncag O, Eronat C, Kose T. A
clinical evaluation of resin-based composite and glass
ionomer cement restorations placed in primary teeth using
the ART approach. J Am Dent Assoc 2006;137:152936.
[20] Louw AJ, Sarvan I, Chikte UME, Honkala E. One-year
evaluation of atraumatic restorative treatment and
minimum intervention techniques on primary teeth. S Afr
Dent J 2002;57:36671.
[21] Beiruti N, Frencken JE, Mulder J. Comparison between two
glass-ionomer sealants placed using nger pressure (ART
approach) and a ball burnisher. Am Dent J 2006;19:15962.
[22] Rahimtoola S, van Amerongen E, Maher R, Groen H. Pain
related to different ways of minimal intervention in the
treatment of small caries lesions. J Dent Child 2000;67:1237.
[23] Honkala E, Behbehani J, Ibricevic H, Kerosuo E, Al-Jame G.
The atraumatic restorative treatment (ART) approach to
restoring primary teeth in a standard dental clinic. Int J
Paediatr Dent 2003;13:1729.
[24] Schriks MCM, van Amerongen WE. Atraumatic perspective
of ART. Psychological and physiological aspects of treatment
with and without rotary instruments. Community Dent Oral
Epidemiol 2003;31:1520.
[25] Van Bochove JA, van Amerongen WE. The inuence of
restorative treatment approaches and the use of local
anaesthesia, on the childrens discomfort. Eur Arch Pediatr
Dent 2006;7:116.
[26] Mickenautsch S, Frencken JE, vant Hof MA. Atraumatic
restorative treatment and dental anxiety in outpatients
attending public oral health clinics in South Africa. J Public
Health Dent 2007;67:7984.
[27] Topaloglu-Ak A, Eden E, Frencken JE. Perceived dental
anxiety among schoolchildren treated for dental caries in
primary molars through three caries removal approaches. J
App Oral Sci 2007;15:23540.
[28] 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.
[29] Lo ECM, Luo Y, Fan MW, Wei SHY. Clinical investigation of
two glass-ionomer restoratives used with the Atraumatic
Restorative Treatment approach in China: two-years results.
Caries Res 2001;35:45863.
[30] Estupinan-Day S, Milner T, Tellez M. Oral health of low
income children. Procedures for Atraumatic Restorative
Treatment. Final Report. Washington: Pan American Health
Organization; 2006.
[31] Wilson AD, McLean JW. Glass-ionomer cement. Chicago:
Quintessence Publishing Co.; 1988.
[32] 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;56:1415.
[33] Frencken JE, Makoni F, Sithole WD. ART restorations and
glass ionomer sealants in Zimbabwe: survival after 3 years.
Community Dent Oral Epidemiol 1998;26:37281.

[34] Smales RJ, Gao W, Ho FT. In vitro evaluation of sealing pits

and ssures with newer glass-ionomer cements developed
for the ART technique. J Clin Pediatr Dent 1997;21:
3213.
[35] Pereira LC, Nunes MC, Dibb RG, Powers JM, Roulet JF, Navarro
MF. Mechanical properties and bond strength of
glass-ionomer cements. J Adhes Dent 2002;4:7380.
[36] Palma-Dibb RG, de Castro CG, Ramos RP, Chimello DT,
Chinelatti MA. Bond strength of glass-ionomer cements to
caries-affected dentin. J Adhes Dent 2003;5:5762.
[37] Czarnecka B, Limanowska Shaw H, Nicholson JW.
Microscopic evaluation of the interface between
glass-ionomer cements and tooth structures prepared using
conventional instruments and the atraumatic restorative
treatment (ART) technique. Quintessence Int 2006;37:55764.
[38] Grossman ES, Mickenautsch S. Microscope observations of
ART excavated cavities and restorations. S Afr Dent J
2002;57:35963.
[39] Sindhu R, Grossman ES. Spreadability of two glass ionomer
cements used in atraumatic restorative treatment (ART). S
Afr Dent J 2004;59:246.
[40] da Silva RC, Zuanon AC, Spolidorio DM, Campos JA.
Antibacterial activity of four glass ionomer cements used in
atraumatic restorati557-564ve treatment. J Mater Sci Mater
Med 2007;18:185962.
[41] Davidovich E, Weiss E, Fuks AB, Beyth N. Surface
antibacterial properties of glass ionomer cements used in
atraumatic restorative treatment. J Am Dent Assoc
2007;138:134752.
[42] Beiruti N, Frencken JE, vant 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;34:4039.
[43] Seale NS, Casamassimo PS. Access to dental care for
children in the United States. A survey of general
practitioners. J Am Dent Assoc 2003;134:163040.
[44] Bulut T, Sharif S. Atraumatic Restorative Treatment in
Nederland. Dissertation. Nijmegen: College of Dental
Sciences; 2004.
[45] Burke FJ, McHugh S, Shaw L, Hosy MT, MacPerson L, Delargy
S, et al. UK dentists attitudes and behaviour towards
Atraumatic Restorative Treatment for primary teeth. Br Dent
J 2005;199:3659.
[46] Mickenautsch S, Frencken JE. Utilization of the Atraumatic
Restorative Treatment (ART) approach in a selected group of
public oral health operators in South Africa 5 years after
training. BMC Oral Health 2009;9:10.
[47] Mickenautsch S, Frencken JE, vant Hof MA. Factors
inhibiting the implementation of the Atraumatic Restorative
Treatment approach in public oral health services in
Gauteng Province, South Africa. J Appl Oral Sci 2007;15:
18.
[48] Kikwilu EN, Frencken JE, Mulder J, Masalu JR. Barriers to
restorative care as perceived by dental patients attending
government hospitals in Tanzania. Community Dent Oral
Epidemiol 2009;37:3544.
[49] Kikwilu EN, Frencken JE, Mulder J, Masalu JR. Barriers to
restorative care as perceived by dental practitioners in
Tanzania. Community Dent Health 2009, in press.
[50] Kikwilu EN, Frencken JE, Mulder J, Masalu JR. Dental
practitioners attitudes, subjective norms and intentions to
practise Atraumatic Restorative Treatment (ART) in
Tanzania. J Appl Oral Sci 2009;17:97102.
[51] Kikwilu EN, Frencken JE, Mulder J. Barriers to the adoption of
ART as perceived by dental practitioners in government
dental clinics. J Appl Oral Sci 2009;17.