This document discusses several studies that evaluated the survival and performance of restorations and sealants placed using the ART (Atraumatic Restorative Treatment) approach. Some key findings from the studies include: - ART restorations caused less discomfort for patients compared to conventional treatments. Survival rates of newer ART restorations placed with glass ionomers were comparable to single-surface conventional amalgam restorations after 3 years. - Studies found ART restorations to be an effective treatment for a large proportion of dental caries lesions. ART preparations were typically smaller in size than conventional preparations. - A 6-year study found no significant differences in success rates between occlusal amalgam, glass ionomer, and ART

1. SURVIVAL OF ART
RESTORATIONS AND
SEALANTS PLACED AS
PART OF THE ART
APPROACH
Jo Frencken
Christopher
Holmgren
Frans Mikx

2. SURVIVAL OF ART
RESTORATIONS AND
SEALANTS PLACED AS PART
OF THE ART APPROACH
Adapted by Kenneth A. Bolin, DDS,MPH

3. Traditional concepts of cavity design
‘The application of a mechanical
design on a biological process'
1
2
3
1
2
3
4

4. Traditional concepts of cavity design
Mechanical retention
 Flat floors
 Vertical walls
 Triangular
retention niches
 Undercut areas
1
2
3
1
2
3
4

5. Biological principals of cavity
preparation
1
2

6. Biological Prep
Don’t remove hard (often discolored) dentin
1
2
3
4
5

9. Plate 18.61 After excavation.

10. ART Applications
Great technique for root caries
Good alternative in field conditions
Excellent for fearful children
Good alternative in medically
compromised patients
Good alternative in mentally
compromised

11. ART restorations in the
permanent dentition
*Frencken, Holmgren, Mikx--WHO
Outcome of studies depends on:
 Material used
 Experience of operator

12. ART restorations in the
permanent dentition
Studies: Material considerations
 Early ART studies: non stress bearing
situations (cervical cavities)
 Later materials perform better than
earlier first generation GIC
 Wear unexpectedly low (approx. 1.5 –
2.5 % assessed)

13. ART in permanent dentition
Studies: Operator effects
 Cambodia
Less experienced operators
Materials used: earlier glass-ionomers
No conditioning in protocol
 Zimbabwe
senior dentist better than junior dental
therapists
 Pakistan
Person to person differences

14. Conditioning of tooth tissues

15. Setting reaction of glass-ionomer

16. Applicability of ART
Study: Effectiveness of the dental hatchet
 Zimbabwe: it was possible to treat
84% of the dentin lesions that were
judged to be in need of treatment.
Access was difficult to dentin lesions
that were present in approximal
surfaces of anterior teeth.
 Study was carried out in a low-caries
prevalance population (41% and a
mean DMFT score of 1.1).

17. Applicability of ART
Study: Acceptance of hand
instruments
 Pakistan: hand instruments
used in ART with glass-
ionomer were better accepted
than rotary instruments and
amalgam

18. Applicability of ART
Study: Size of cavity preparations
Pakistan: Using cylindrical insets, the
size of preparations were measured in
mm3. The mean size of restorations
produced by hand (ART) and rotary
(drill) instrumentation was 5.1 and 6.1
mm3, respectively.

19. Applicability of ART
Study: Discomfort during ART
treatment--Pakistan
 Restorations using ART were compared to
those placed using conventional
procedures
 Patients aged 6-16 years were asked if
the treatment they received was painful
 Operative sensitivity was less (19%) in
restorations placed with ART than in
those placed using the drill and amalgam
(36%)
 Discomfort was higher in large than in
small size preparations.

20. Applicability of ART
Study: Post operative sensitivity
Zimbabwe:
 Observed in 5-6% of the ART
restorations placed
 Later information was collected 2-4
weeks after placement. At that
time, sensitivity had disappeared
for all but one of 197 restorations

21. Applicability of ART
Study: Acceptability of ART by care
receivers in South Africa
 Staff members had difficulties in
treating rural primary schoolchildren
since many were fearful of the dental
treatment delivered by the mobile
system.
 A year after the introduction of
ART, extractions were reduced by
17% for permanent and by 36% for
primary posterior teeth compared to
the year prior to ART.
1
2
3

22. Applicability of ART
Study: Acceptability of ART by care
receivers in South Africa
 Percentage of amalgam restorations was
reduced by 16% in permanent and 1% in
primary teeth.
 Conversely, restorative care increased by
33% in permanent and by 37% in primary
posterior teeth.
1
2
3

23. Applicability of ART
Study: Acceptability of ART by care
receivers in South Africa
 Positive change was ascribed to the
patient-friendly nature of ART which had
reduced fear, mainly because of the
absence of injections: children’s
acceptance of restorative care increased
 Another advantage was the simplified
infection control, very relevant in an area
with a high prevalence of HIV and hepatitis
1
2
3

24. ART- and conventional
restorations compared
Quality of restorations depends on:
 Material
 Operator
 Patient
Longevity of amalgam and
composite resin restoration varies
tremendously (ranges from 3 to more
than 20 years).

25. Conventional Restorations
Longevity

26. ART vs. Conventional

27. Survival of ART restorations

28. Performance of ART
Restorations
A very large proportion of dentine
lesions can be treated using the ART
approach.
Single-surface ART restorations were
smaller in size than those produced in
the conventional way, using rotary
instruments.
ART approach caused less discomfort
than the conventional approach.
1
2
3

29. Performance of ART
Restorations
Survival of the more recently placed
single-surface ART restorations was
higher than that of ART restorations
placed in the early studies
Survival of single-surface ART
restorations after 3 years with newer
glass-ionomers was comparable to that
of single-surface conventional
restorations placed using amalgam
after 3 years
1
2
3

30. Survival of ART restorations
in the deciduous dentition
More studies are needed to arrive at
a conclusion as to the survival of ART
restorations using glass-ionomers in
the deciduous dentitions
Failure rates for amalgam are similar
in some studies

31. Performance of ART
Restorations
ART needs to be considered as a caries
treatment modality that benefits people
ART should be taken seriously by the
dental profession and dental schools
Organized educational courses need to
be taken prior to applying the approach
in the field and clinic
1
2
3

32. What about leaving decay?
ART critics decry technique which
arguably leaves “decay” in prep
Critics allege that due to lack of
complete decay removal, caries
process continues (resumes)
Critics say that only by using a bur
can all decay be removed (remove all
stain)

33. What about leaving decay?
Study needed to measure types and
quantities of bacteria in ART preps
Bacteria counts measured in the soft
dentin excavated
Counts compared to samples from
the hard walls after hand prepping

34. Microbiological Results
Statistically significant lower mutans
strep bacterial counts (p<.0001)
Statistically significant lower
lactobacilli counts (p=.0002)
Significant decrease in total bacterial
counts (p<.0001)
About 50% of cavity preps had
undetectable levels of mutans
streptococci

35. Microbiological Results
The significant decrease in bacteria
after manual cavity preparation
demonstrates the reliability of a
standardized ART technique
Presence of S. Mutans strains shows
the effectiveness of the ART
procedure can vary among operators

36. Microbiological Results
Numbers of bacteria remaining were
of low clinical significance & were
comparable to mechanical prep
methods
ART works against the remaining
bacteria by bacteriostatic effect of
the glass ionomer and/or sealing
effect of the restorative material
 Toi CS, Oral Microbiol Immunol 2003:
18: 160-164

37. ART Effect on Oral Bacteria
Known attributes of ART & Glass
Ionomer materials
 Adhesive properties
 Degree of wear resistance
 Biocompatibility
 Fluoride release
 Remineralization capabilities
Unknown effect on salivary mutans
strep levels

38. Prior studies
Significant lowering of mutans
streptococci in saliva after placing
amalgam restorations immediately
post-op
 12-18 months later—high MS levels &
new caries present
Authors concluded that elimination of
decay with alloy an incomplete
method for eliminating MS in plaque

39. Prior Studies
Using IRM (zinc oxide/eugenol)
resulted in a drop in MS 48 hours
post-op
After one week MS counts increased
10 fold
One month after treatment, levels
were similar to those encountered
prior to any treatment

40. ART Effect on Oral Bacteria
ART using Fuji IX+Fuji conditioner
was performed on 5-7 y.o.
Only primary teeth were restored
MS levels taken prior to any
treatment using Cari-test SM system
All treatment was done without
power instruments by dentists

41. ART Effect on Oral Bacteria
Salivary tests performed at one
week, four weeks, and one year
One week—95.9% reduction in MS
4 weeks—93.2% reduction
One year—95.5% reduction
 Caveats: Small sample size lacks power
 Children were receiving fluoride
treatments q 6 months

42. Conclusions
Statistically significant reduction in
pre and post levels of mutans
streptococci in saliva (p<.05) when
using ART with Fuji IX material
Differences in test results at one
week, one month, and one year not
statistically significant
ART helped reduce levels of MS in
saliva
 Carvalho CKS. Int’l J Pediatric Dent
2003; 13:186-192

43. 24 month Randomized Clinical
Trial Comparing PCR & CR
Pediatric Department at Dundee
Split-mouth randomized controlled
clinical trial
Used previously unrestored matched
caries in non-pulpally involved
primary molars
Partial caries removal (PCR:GIC)
Complete caries removal and
conventional restoration (CR)

44. 24 month Randomized Clinical
Trial Comparing PCR & CR
Objective: To determine durability
and effectiveness using a glass
ionomer cement coupled with partial
caries removal, and compare these
results with complete caries removal
and conventional restoration
Outcomes Measure: Median survival
time (MST) up to 24 month limit

45. PCR:GIC vs CR Group
PCR: Instrumentation limited to
gaining access to the caries, removal
of soft caries to allow enough bulk
(3mm) of material (Chemfil Superior)
CR: Complete removal of caries with
rotary instruments using retentive
undercuts if amalgam was used, but
also GIC was used if operator chose

46. Results
Most failures occurred in GIC within
the first 6 months
PCR:GIC demonstrated comparable
durability and effectiveness as
conventional restorations over the 24
month period
MST of both types of restorations
was 24 months, so longevity is
understated
 Caveat: Small sample size lacks power
 Foley J, et al. BDJ 2004; 197: 697-701

47. Six-Year Success Rates of
Occlusal Amalgam and Glass-
Ionomer Restorations
Randomized clinical trial
Dental caries in occlusal surfaces
Non-gamma-2 amalgam and a
low-viscosity glass-ionomer as
the restorative material

48. Split-mouth design was used
Materials were randomly placed in
430 matched contralateral pairs of
permanent molar teeth
152 children from five primary
schools were recruited and treated
by a dental therapist
Restorations were evaluated after 6
years by 2 calibrated independent
examiners
Six-Year Success Rates…

49. Six-Year Success Rates…
6-year successes for all occlusal
amalgam = 72.6%
For all glass-ionomer restorations
successes = 72.3%

50. Six-Year Success Rates…
No statistically significant differences
observed between the successes for
both amalgam and glass-ionomer
restorations placed
By the ART approach
 (68.6%, with 95% CI = 61-76%)
Or by the conventional
 (74.5%, with 95% CI = 65-82%)

51. Six-Year Success Rates…
No statistically significant difference
observed between the successes of
occlusal ART restorations with glass-
ionomer materials
 (67.1%, with 95% CI = 56-77%)
And occlusal conventional amalgam
restorations
 (74%, with 95% CI = 61-85%)

52. Reasons for Failures
'Restoration fracture/marginal
defects'
‘Loss of material'
The former was more often
recorded in amalgam
restorations and the latter in
glass-ionomer restorations

53. Reasons for Failure
Secondary caries was observed
for 2% of glass-ionomer and for
10% of amalgam restorations
This difference was statistically
significant (p = 0.001)

54. 6 Year Success Summary
The ART approach using glass-
ionomer performed equally well as
conventional restorative approaches
using electrically driven equipment
and amalgam for treating dentinal
lesions in occlusal surfaces after 6
years.
 Mandaria GJ, et al. Caries Research
2003;37:246-253

55. ART-GIC for Root Caries
Properly placed glass ionomer
restorations are durable and
clinically successful
Ketac-Fil restorations of Class V
lesions had 80% 10 year retention
rate
 Matis BA, et al. Quint Int 1996; 27:373-82

56. ART-GIC for Root Caries
Clinical trials showed a 30%
reduction in recurrent caries around
GI restorations in high caries risk
patients
 Erickson RL, et al. J Dent Res
2001;80:641
Ketac-Fil lasted longer than amalgam
in xerostomic, head and neck
radiation patients
 Wood RE, et al. Oper Dent 1993; 18:94-
102.

57. Materials Choice in Root Caries
Conventional Glass Ionomers
Resin-modified Glass Ionomers
 Bond to tooth structure
 Have long-term fluoride release
 Can be “recharged” with F treatment
Compomers
Composites
 Neither release fluoride or recharge
 Neither bond without bonding agents

58. Academy of Operative
Dentistry Recommendations
Not all root caries lesions require
restorative treatment
 Shallow lesions made caries free by
use of hand instruments or
polishing disks
 Arrested or leathery surfaces
amenable to treatment with
fluorides and CHX

59. Academy of Operative
Dentistry Recommendations
When root caries require restoration
there is general agreement that,
when possible, adhesive fluoride
releasing materials are preferred
 GIC or Resin-modified GIC
materials
 Operative Dent, 2004, 29-6, 601-7

60. Fuji IX Hand Mix Package

61. Fuji IX Capsules

62. Ketac-Molar Packaging

63. Evaluating ART Glass-
Ionomer Restorations

64. Evaluation criteria for ART
Wear
 Margin of restorations
 Marginal breakdown
 Overall surface wear
Set cut-off point
 Pragmatic, easy to use and reproducible
 Identify glass-ionomers problems

66. Score 0: Present, good

67. Score 1: Present, slight
marginal defect

68. Score 2: Present, marginal
defect

69. Score 4: Not present

70. Score 7: Present, some
wear and tear <.5mm

71. Score 8: Present, wear
and tear >.5mm

72. Survival of glass-ionomer
sealants in ART approach
Effectiveness glass-ionomer sealants
 Sealing with glass-ionomer as
part of “Press-finger" technique
in ART approach
 “Press-finger" technique
showed good penetration (in vitro
study)
 Penetration better than
conventional means

73. Press-finger technique

74. Press-finger technique

75. After pressing

76. After applying waterproofing

77. Survival of GIC sealants
3 year old glass-ionomer sealant

78. Survival of GIC sealants
2 year old glass-ionomer sealant

79. Evaluation Criteria for
Glass-ionomer ART
Sealants

81. Performance of glass-
ionomer sealants in ART
approach
Success of a sealant should be
expressed in terms of caries prevention
Biological outcomes should take
precedence over mechanical outcomes

82. Performance of GIC sealants
in ART approach
2 Studies in Zimbabwe: Considering
sealant retention
• Both studies sealed only tooth surfaces that
had early enamel carious lesions that were
either active or inactive.
• In addition, the most recent study only
sealed such surfaces in high-risk individuals
that had patent fissures.

84. Performance of GIC sealants
in ART approach
Studies: Considering caries prevention
• Sealing inactive or active early enamel
carious lesions with glass-ionomer as
part of the ART approach seems to be
beneficial
• In Zimbabwe comparable surfaces that
were not sealed had a 4 times higher
chance of developing dentin lesion
than those sealed after 3 years

85. Performance of GIC sealants
Overview of caries free sealed surfaces -- permanent teeth

86. Performance of GIC
Sealants in ART approach
Studies: Operator considerations
• As with ART restorations, an
operator effect was observed in the
earlier Zimbabwe study
• Younger, less experienced operators
performance below that of more
experienced ones

87. GIC vs. Resin Sealants
Retention considerations
• Originally, a low powder/liquid glass-ionomer
was used
• Sealants using the low powder/liquid glass-
ionomers had a very low retention
• Higher powder/liquid glass-ionomers
exhibited better retention
• Press-finger technique had better results
• Resin based sealants in general have better
retention but lack the fluoride effect
1
2

88. GIC vs Resin Sealants
Caries prevention considerations
• Caries development in sealed surfaces with
early enamel lesions after 3 years with glass-
ionomer was low
• The overall caries preventive effect of
sealants seems to be dependent on the caries
activity in the mouth
• The literature is inconclusive as to which of
the sealants i.e. composite resin or glass-
ionomer, prevents caries best
1
2

89. Radiopaque GIC Sealant

90. Coding and Billing
ADA CDT 4 Code book says “Glass
ionomers, when used as restorations,
should be reported with these codes
(resin-based composite restoration
codes—anterior or posterior). Resin-
based composite refers to a broad
category of materials including but
not limited to composites.”

91. Coding and Billing
If planning to replace the GIC
restoration in less than a one year
time period, use code ADA CDT Code
2940—Sedative Filling
Coding should not be based on the
technique of cavity preparation
Coding systems were developed
before the advent of ART and Glass-
Ionomer restorative materials

92. Coding and Billing
Coding for sealants is ADA CDT Code
1351 and is used for either resin
based sealants or GIC based sealant
material
Same limitations exist i.e. age,
quadrant limitations depending on
insurance criteria or Medicaid
policies of your state

93. Questions?