A General dental treatment for restorative procedures requires a lot of equipment involving Electricity in every Dental clinic, but in developing and backward countries some places do not have access to basic amenities like electricity, etc. So Atraumatic Restorative Treatment or ART is a procedure to restore decayed teeth in such places without the use of electricity powering Handpieces etc. In the Atraumatic Restorative treatment technique, Hand instruments are used to remove carious lesions and are restored using only Hand Instruments. ART technique was first evaluated in the mid-1980s in Tanzania due to its lack of basic facilities and other such places have since used this technique extensively. In situations like the Coronavirus Pandemic, the ART technique is the way to go as it doesn’t lead to the production of Aerosols.

ART Definition: By the American Academy of Pediatric Dentistry, “A dental caries treatment procedure involving the removal of soft, demineralized tooth tissue using hand instrument alone, followed by restoration of the tooth with an adhesive restorative material, routinely glass ionomer”. 

The three Goals of the ART technique are Avoiding discomfort, Reducing infection and preserving the tooth structure. The Principles of ART – Removing the carious lesions using hand instruments and restoring the cavity with a restorative material that bonds (Glass Ionomer Cement) to the tooth.

Atraumatic Restorative Treatment technique

When can ART be used:

ART technique can also be used in your daily practice on patients who have phobia’s about dental instruments like Aerator etc or in mentally challenged patients or Children who might become uncooperative due to air, sound or vibrations from the Aerator. With the recent Coronavirus Pandemic, the Atraumatic Restorative Treatment technique can be useful in providing Emergency Dental Treatments which can prevent the production of Aerosols which play a major role in spreading the pandemic.

Atraumatic Restorative Treatment indications

ART Technique uses simple hand instruments to aid in the removal of Dental Caries and restoration of the lesion using Cement. There are many limitations to this technique as the types of lesions which can be treated using this technique are few. Only Soft caries can be removed and restored while secondary and Arrested caries which is hard in consistency cannot be removed using hand instruments.

Indications of Atraumatic Restorative Treatment (ART):

  • Class I Occlusal Pit and Fissure caries of small size with sound tooth structure on all sides of the restoration
  • Children, Mentally Challenged, patients with phobia’s, home care service, senior citizens, refugees (minimal equipment support), etc are the ideal patient pool to use ART procedure on
  • Backward countries with limited exposure to Electricity, water, etc.
  • Public health camps or programs

Contraindications of Atraumatic Restorative Treatment (ART):

There are certain situations where ART technique cannot be performed due to many limitations which are explained below.

  • Abscess or Fistula on a carious tooth
  • Swelling associated with an infected tooth
  • Inaccessible to attain access opening by hand instruments
  • Hard tooth structure preventing hand instruments to attain cavity preparation

Advantages of ART:

  • Used to treat patients with Phobias from Rotary instruments
  • Less Traumatic to tooth
  • Preserve sound tooth structure
  • Painless
  • Cost Effective
  • Can be used in places where Dental Equipment is not available
  • Treatment option for Mentally and physically abled patients, elderly patients in nursing homes, etc
  • Prevents Aerosols formation helping in infection control

Atraumatic Restorative Treatment Procedure:

Restorative material used in ART is Glass Ionomer cement (GIC) as it bonds chemically to both enamel and dentin which reduces the need for removing sound tooth structure to achieve retention. GIC releases Fluoride which helps in arresting caries. It does not harm the pulp tissue.

Instruments used in ART are mouth mirror, explorer, tweezers, spoon excavator 1 mm in diameter (to remove the soft carious tissue), Enamel hatchet, Carver, PFI (filling instrument), Condenser, cotton rolls, petroleum jelly, matrix bands and wedges (Class 2 cavity), gloves, mouth mask, sterilization equipment, etc.

Steps in Atraumatic Restorative Treatment:

Isolation of the working field: Isolate the tooth in question which is being treated with cotton wool rolls placed beside the teeth on either side to prevent saliva from entering the working field.

ART technique cavity preparationCavity Preparation: Dry the tooth surface using a dry cotton pellet, now using the spoon excavator to remove Soft caries in a spooning movement. If you are not able to remove entire caries with the excavator you need to widen the cavity entrance with the help of the enamel hatchet or carver. Remove any unsupported or overhanging enamel with the enamel hatchet and remove entire caries or affected enamel or dentin. Now dry the cavity using a wet cotton pellet. Use a dentine conditioner or tooth cleaner (10% polyacrylic acid) to remove any tooth debris left, removing this smear layer helps in the bonding of GIC. You can use GIC liquid to clean the cavity as well.

Filling the Cavity: Glass Ionomer cement is taken and mixed on a mixing pad along with a plastic spatula. Dispense the powder on the mixing pad and divide the powder into two equal portions using the spatula, not dispense a drop of liquid beside the powder. One half of the powder should be mixed first using a folding motion and then the second half of the powder needs to be mixed – the whole mixing procedure should be completed in 20-30 seconds. The mixed cement should have a chewing gum-like consistency.

Carry the prepared mixture using a PFI instrument and place a small amount into the prepared cavity and condense it to prevent any voids or air to be entrapped at the base of the cavity, the process should be repeated to completely fill the cavity in 30-40 seconds only. Apply a small amount of Petroleum jelly on your fingertip and press on top of the restorative cement when it is soft in consistency. Slide the finger to the sides to remove any excess cement from the cavity. Using a carver remove the excess material. Apply a layer of petroleum jelly on top of the filled restoration which prevents saliva from touching the restoration. Advice the patient to not eat or drink for 1 hour and not to chew on the side of the filling for 24 hours.

For class two cavities using a matrix band and wedge is a must after tooth preparation.

ART being a minimally invasive technique helps in treatment as well as prevention of the spread of dental caries and stops further progression of the lesion.

References:

Eduardo Bresciani Clinical Trials with Atraumatic Restorative Treatment in Decidiuos and permanent teeth J Appl Oral Sci. 2006;14

Jo E. Frencken Christopher J. Holmgren Caries management through the Atraumatic Restorative Treatment approach and glass-ionomers:  update 2013 Braz Oral Res., Sao Paulo 2014

Jo E. Frencken Evolution of the ART approach: highlights and achievements J Appl Oral Sci. 2009; 17 (sp. issue):78-83