: Atraumatic Restorative Treatment Slide 2: Although dental carries has decreased substantially in the industrialized countries over the last two to three decades from a global prospective, it remains a widespread problem. caries lesion not only tend to go untreated in people living in underprivileged community in developing countries, but also in highly industrialized countries. untreated carious often progress to a stage that when treatment is provided that can be done by extraction of the tooth. until now the treatment has require expensive equipments and highly qualified personals. further in many situations the electricity absence and clean pressurized water sometimes make it impossible for the health care person to work
A new method for treating dental caries that involves neither drill water nor electricity was presented at the headquarter of the WHO Geneva on world health day on 7april 1994. on occasion that also marked the beginning of the year of oral health .the procedure called as ATRAUMATIC RESTORATIVE TREATMENT.
It Consists of manual cleaning dental cavities with hand instruments and filing them with an adhesive fluoride releasing material. To use this procedure oral health care workers need only a few instruments that can be carried easily with them.. Slide 3: It is popular among millions of peoples because it is non threatening ,non painful, low cost it is also simple to train out and the instruments can be carried out in a bag so it is more effectively reached to the community. ART provides care for decayed teeth which is non threatening and low cost and can prevent extraction in most cases.
ART was pioneered in the mid 1980s in the tanjania and the careful application of ART decreases 85% of chances of caries for 3 years Slide 4: INSTRUMENTS & MATERIAL USED
The essential instruments of ART. The correct instruments should be used for each treatment procedure. The success of any treatment depends on the operator knowing the function of the various instruments and using them correctly.
(1)Mouth mirror:-to reflect light onto the field of operation, to view the cavity indirectly and to retract the cheek or tongue.
(2)Explorer:-to identify where soft caries dentin is present. Do not poke the point into very small caries lesion. This may destroy the tooth surface and the caries arrestment process. Also do probe into deep cavities where you might damage or exposure the pulp.
(3)Pair of tweezers:-to carry cotton wool rolls, wedges. do not poke the point into very small carious lesion. Slide 5: (4)Small and medium sized spoon excavators:-this instrument is used to remove soft carious dentine. small excavator have a diameter of 1 mm. this instrument is for use in small cavities and for cleaning the enamel/dentin junction. the diameter of this medium spoon is 1.5 mm. it is used for removing soft caries from large cavities rounded surface is used to push the material into small cavities.
(5)Dental hatchets:-this instruments is used for widening the entrance to the cavity, for slicing away the unsupported and carious enamel left. The width is 1 mm.
(6)Applier and carver:- this double ended instrument has two functions. blunt end is used for inserting GIC into the cavity and sharp end is used to remove the excess material and shape the restoration.
(7)Mixing pad and Spatula:-the mixing pad is made up of paper that is supplied with the cement and the spatula may be metal or plastic.
(8)Light source:-a pair of spectacle frames that is powered by a rechargeable battery source is used. Slide 6: The essential materials:-
(1)Gloves:-for hygiene purpose, to wear on the hand.
(2)Cotton wool rolls:-to absorb the saliva.
(3)Pellets:-for cleaning the cavity. the smallest 4 for small cavities and 2 for large cavities.
(4)Petroleum jelly:-prevents GIC sticking to the gloves and for final insulation.
(5)Wedges:-these are used to hold the plastic strips close to the shape of proximal surface of a tooth so that restorative material is forced between the tooth and gums.
(6)Plastic strips:-used for contouring the proximal surface in multiple surface restorations. Slide 7: WHAT TO DO BEFORE APPLYING ART?
Before you actually start the atraumatic restorative treatment of a carious lesion in a tooth you should know how to
(1)Arrange a good working environment in and outside the mouth.
(2)Select and to use the correct instruments.
(3)Control cross infections.
(4)Use the GIC material. Slide 8: (1)Arrangements outside the mouth
The correct positioning of both the operator and patient is essential to achieve good quality care. The work posture and position of the operator should provide the best view of the inside of the patient s mouth at the same time both patient and operator should be comfortable. The distance from the operators eye to patients tooth is usually between30-35 cm. the operator should be positioned behind the head of the patient the exact position will depend on the area of the patient mouth to be treated. The most common position are 12 o and 10 o clock. When treating patients particularly children using ART it is a great advantage if another person can mix the GIC. This allows the operator to concentrate on the cavity and maintain effective saliva control. The assistant 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.
Operating light-good vision is essential for working in the oral cavity. The light source can be the sun or the artificial. Artificial light is more reliable and constant than natural light and can also be focused to a particular spot. Slide 9: (2)Arrangement in the mouth
A dry operating area, 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.
(3)HYGENE AND CONTROL OF CROSS INFECTIONS
Always wear gloves
Cleaning and sterilization is necessary to prevent infection
Cleaning of the surface can be done by cotton and methyl spirit
In the clinic the instruments can be sterilized by autoclave or a pressure cooker
All these preventive measures prevent the spread of HIV and HBV. Slide 10: GLASS IONOMER CEMENT
The material that we use in the ART is glass ionomer cement and it can be used as both the prevention and treatment using hand instruments.
Glass ionomer is very useful as dental restorative material because:-
(1)They can be applied to caries in very early lesions.
(2)Is adheres to the tooth structure chemically.
(3)it is anticariogenic because it releases fluoride.
(4)It is same as hard tissue and does not inflame the pulp and gingiva. Slide 11: The procedure for caries removal for one surface cavities step by step
(1)Place cotton wool rolls alongside the tooth to be treated.
(2)Remove plaque from tooth surface with wet cotton wool pellets.
(3)Dry the tooth surface with dry cotton wool pellets
(4)If necessary make the entrance of the cavity wider with a dental hatchet.
(5)Remove the carious dentin with excavators starting at the de junction.
(6)Fracture off unsupported thin enamel with the hatchet. Make sure the enamel does not contain any carious lesion.
(7)Clean the cavity with wet and then dry cotton wool pellets. Slide 12: (8)Remove the caries near the pulp carefully, and provide pulp protection if necessary.
(9)Clean the cavity again with wet cotton wool pellets. (8)insert the mixed GIC into the cavity cavity and overfill slightly. Press petrolium jelly with coated gloves fingers from the top of the occlusal plane surface and apply slight pressure. This is called Press finger technique.
(10)ask the patient to bite to check the bite relations.
(11)Remove the excess material with carver.
(12)Recheck the bite and adjust the height of the restoration until comfortable.
(13)Cover the filling or sealants with petrolium jelly once again or apply varnish.
(14)Instruct the patient to not eat at least for one hour. Slide 13: In order to enhance the adhesiveness between the tooth and GIC, cavity walls must be clean.
Other chemicals for this purpose are dentin conditioners. They are 10% solutions of poly acrylic acid. apply one drop of this by holding by the tweezers for 10-15 seconds
Note:-In case of multiple surface restoration only there is use of plastic strips and wedges. Slide 14: Failed or defective restoration:-
A restoration may not be acceptable or unsatisfactory anymore for several reasons.
It is completely missing.
a large part of it has broken away.
the restoration is fractured.
much of the restorative has worn away.
carries has developed at the restoration margin or elsewhere on the tooth surface. Restoration is completely missing : Restoration is completely missing Contamination with saliva or blood during the restorative procedure .
Mix of material was too wet or too dry.
Not all the soft caries had been removed.
Thin undermined enamel had been left behind and this later broke off. Slide 16: 2. Part of the restoration has broken away
it is probable that the restoration was too high or air bubbles were trapped in the material during the placement of the restoration.
whatever the reason clean the tooth surface and/or remaining restorative material with an explorer or small excavator and wet cotton wool pellets first, before conditioning the entire surface and material.
fill the gap with a new mixture of GIC and ensure that the restoration is not too high
3. The restoration has fractured
This most commonly happens in a multiple surface restoration which was too high. the way to repair it very much depends on the location of the fracture line and the mobility of the fractured part. If the fractured part is loose and can be removed, repair the gap as describe as above. however if the fractured part can nt be removed repair through ART is not possible and traditional treatment using a drill is needed. Slide 17: 4. The restoration has worn away
Possible reason for this are the patient eats very hard food frequently, the patients clenches his/her teeth frequently otr the mixture had been too wet or too dry. It may take airs, but it is possible that so much material has been lost that the restoration should be rebuilt. ensure that all the surface of the tooth and the remaining restoration are clean and free from sot tooth tissues. Apply dentin conditioner over the glass ionomer and the cavity walls . Place an new layer of Gic on top of the old one. finish the restoration as described earlier.
5. Caries has developed in the adjacent fissure or sulcus
Remove the soft tissues after all decay has been removed. Clean and fill the new cavity adjacent to he restoration according to the standard procedure. : In the ART we use hand instruments rather than electric instruments. The cause are as follows:-
(1)It makes restorative care for all peoples.
(2)Biological approach with minimal cavity preparation. in the conservative dentistry we design the cavity in such a way that it can support the restoration like amalgam. So there is more tooth loss.
(3)Low cost of hand instruments.
(4)as there is no pain so there is no need of anesthesia and so there is no psychological fear.
(5)There is good infection control because the instruments can be sterilized on regular basis. : (6)For caries involving dentin only.
(6)It cant be used with one surface cavity in permanent teeth and no need in deciduous because they are ultimately replaced by permanent teeth.
(7)ART restoration can help maintenance a natural teeth eruption pattern and avoid disturbance position of permanent teeth.
(8)Effect of cavity depth large depth is bad for ART small to moderate is good both in terms of success and they can wear so modified GIC can be used to prevent this. Slide 20: Disadvantages:-
(1)In the presence of abscess or fistula near the tooth.
(2)Where there is pulp is exposed .in this case we have to do root canal treatment.
(3)Painful teeth and the pulp inflammation.
(4)The opening of pulp is in accessible to the hand instruments. eg-in the proximal caries there is clear sign of cavity but the instruments cant reach that point.
It is not compromise but a perfect alternative treatment approach for developing countries