A review on the concept of Atraumatic Restorative Treatment it focuses on the definition, concept. indications, contraindications, history and functionality of this treatment

1. ATRAUMATIC RESTORATIVE TREATMENT IN DENTISTRY Review
ABSTRACT
Atraumaticrestorative treatment(ART) issuggestedforusage globally,notjustinpoorernations,butalsoinmore
developedones.AtraumaticRestorative Treatment(ART) iswidelyrecognisedamongbothchildrenandadults.ART
isfocusedonpreservingasmuchhealthytoothtissue aspossible whilecausingaslittle agonyaspossible.The use of
handinstrumentsalsominimisespainowingtothe reducedvibrationsthatoccurwhen rotary dental instruments
are used.The use of minimallyinvasive dentistryandpatientcomfortare critical,especiallyforschool-agedchildren
and apprehensive orunwillingpatients.
INTRODUCTION
Dental caries(DC) isdefinedasaninfectious
microbiologicdiseaseof the teeththat resultsin
localizeddissolutionanddestructionof the calcified
tissues1
.Dental cariesisthe mostcommondental
illnessinthe world,althoughitoftengoesuntreated
indisadvantagedgroupsinbothdevelopingand
developedcountries.The WorldHealth Organization
activelyadvocatesatraumaticrestorativetherapyasa
feasible waytomeetingthe demandfordental caries
therapy.Atraumaticrestorative therapyisnow
practisedin25 countriesandispart of regulartraining
programmesfororal workersin at leastthree of
them2
. Atraumaticrestorative treatment(ART),also
known as Alternativerestorative therapy,isdefinedas
"a dental cariestreatmentprocedure involvingthe
removal of soft,demineralizedtoothtissuewitha
handinstrumentalone,followedbyrestorationof the
toothwith an adhesive restorative material,
commonlyglassionomer." The WorldHealth
Organizationandthe International Associationfor
Dental Researchhave bothrecommendeditasa
methodof healingandpreventingcarieswith the aims
of conservingtoothstructure,decreasing infection,
and minimisingpain3
.
A BIT OF HISTORY
ART was initiallydevelopedbythe dentistJoFrenckeninTanzaniain1985 where the care of rottingteethinchildren
livinginanimpoverishedregionwasdifficultdue tolimiteddentistavailabilityandalack of power and/orpiped
water. The disease/care patternmeantthatchildren'steethrotteduntil theycausedpain/infectionandhadto be
removed.Atthe time,dentistsattemptedtoopenand/orwidentinycavitiesusinghanddevicesandselectively
remove decayingtissue,followedbythe implantationof anadhesive filling. More recently,atthe International
CariesConsensusCollaboration(ICCC) meetinginLeuvenin2015, an internationalgroupof cariology,restorative,
and paediatricdentistryexpertsrecommendedARTasa treatmentoptionfordecayedprimaryandpermanentteeth
with decaywhere restorative optionswere indicated,suchascavitiesthatwere difficulttocleanusingonly
toothbrushes.4
Presented by Ishaan Adhaulia & Gurkiran Kaur
Interns (2020-2021) Bharati Vidyapeeth Dental College & Hospital, Pune, Maharashtra.

2. ATRAUMATIC RESTORATIVE TREATMENT IN DENTISTRY Review
IDEAL REQUISITES OFARTMATERIAL [5]
The ideal requisitesof ARTare as follows :
1) Shouldbe biocompatible
2) Shouldbe toothcoloured
3) Shouldhave good handlingproperties
4) Shouldbe insensitive tomoisture ordesiccation
5) Shouldhardenwithoutspecial equipment
6) Shouldformstable bondstoenamel anddentin
7) Shouldseal marginal gapsagainstbacteria
8) Shouldrelease fluoridesand/orre-mineralizationagents
9) Shouldrelease achemotherapeuticagentwhenrequiredtoarrestdisease
10) Shouldexhibitexcellentdurability
INDICATIONS FOR ART [6]
The indicationsforARTare basedon the strengthof approach incertainsettings,aswell asthe evidence foundation
for itssuccess.Asa result,the indicationsmaybe separatedintotwocategories: atthe patientandthe tooth level.
At the patient’slevel : One of the keyfeaturesof the
ART strategyat the patientlevel isthatitishighly
acceptedbypatients.The highlevel of acceptabilityis
due to the fact that, unlike mosttypical restorative
treatmentsforcritical teeth,ARTseldomnecessitates
the administrationof alocal anaesthetic.Thisispartly
due to the approach's minimallyinvasivecharacter,in
which onlynecrotictissue isremovedandremaining
soundtissue ispreserved.Furthermore,because
rotational instrumentationisnotemployedwithART,
the menacingsoundfromthisas well as the required
high-volume suctionare missing.
At the tooth level : There iscurrentlyevidence that
ART single-surface restorationsmade withhigh-
viscosityGIChave a goodsurvival probabilityinboth
primaryand permanentteeth.GiventhatART
restorationsare bothminimallyinvasive andcaries
protective whencomparedtoothertraditional
restorative procedures,ARTrestorationsmaybe
regardeda therapyof choice for single-surfacecaries
lesions. The evidence impliesthatARTrestorations
can be employedformultiple surface carieslesionsin
primaryteeth,butthat the survival ratesare worse
than those forsingle-surface restorations,aswith
othermultiple-surface restorationsinprimaryteeth.
CONTRAINDICATIONS FOR ART [7]
ART fillingsshouldnotbe usedwhenthere is:
1. Swellingora fistulanearthe decayedtooth
2. Pulpal exposure(the nerveof the toothisvisible)
3. Historyof painfromthe teethto be treated
4. Lesionsthatcannot be accessedwithhand instruments(proximal side)
5. Multi-surface cavitiesinpermanentteethand
6. Teeththat are badlybrokendown,which are un-restorable

3. ATRAUMATIC RESTORATIVE TREATMENT IN DENTISTRY Review
MATERIALS, INSTRUMENTATION & METHODS [8]
Instruments: Mouth Mirror, Explorer,Pairof tweezers,Dental Hatchet,SpoonExcavator,small Spoon excavator,
mediumSpoonexcavated,large Applier/carver,Glassslaborpapermixingpadand Spatula
Materials : Cottonwool roll,cottonwool pellet,Cleanwater,Glass-ionomerrestorationmaterial,Liquidand
powdermeasuringspoon,Dentine conditioner, Petroleumjelly,WedgePlasticstrip,Articulationpaper
Operator Consideration :
The operator'sworkpostureand positions:
1) It shouldprovide bestviewforthe operatorinside of the patient’smouthandbothoperatorandpatient
shouldbe comfortable.
2) The operatorsits firmlyonthe stool,withstraightback,thighsparallel tothe floorandboth feetflatonthe
floor.
3) The head andneck shouldbe still.
4) The heightof the stool must allowvisiontothe patient’steethclearly.
5) The distance fromthe operator’seye topatient’stoothisusuallybetween30and 35 cm.
6) The operatorshouldbe positionedbehindthe headof the patient.
7) The exact positionwill dependonthe areaof the patient’smouthtobe treated.
8) Assumingthe patient'smouthisinthe middle of aclockface,the range of positionsfromwhichthe operator
may doall activitiesisonanarc from10 to 1 on the clock.
9) The most typicallyutilisedpositionsare the straightrearposition(at12 o'clock) and the rightrear position
(at 10 o'clock).
Patient Position
1) ART requirescorrectpatientandoperatorpositions.
2) A patientlyingonthe backon a flat surface will provide acomfortable andstable positionforlengthyperiod
of time.
3) A headrestmade of firmfoamor a rubberringwith a cover that improvesthe comfortof the patient.
4) So the patientshouldbe placedona flatsurface,e.g.a bambooor woodenbed,an appropriate portable
dental bed,ora table..
5) The patientispositionedsothatthe salivacollectsinthe backof the oral cavity.
6) The operatingfieldisnowoverthe operator’slapat the heightof the operator’schest.
ART : STEP BY STEP [9]
Step1 : PreparationOf The Art InstrumentsAndMaterialsBefore The Clinical Procedure
Step2 : IsolationOf The OperatingSite
Step3 : ExaminingThe CavitatedTooth
Step4 : GainingAdequate AccessToThe CariesLesion
Step5 : CavityCleaning

4. ATRAUMATIC RESTORATIVE TREATMENT IN DENTISTRY Review
Step6 : ConditioningThe CavityAndAdjacentPitsAndFissures
Step7 : MixingGIC
Step8 : RestoringThe CavityAndFillingThe PitsAndFissures
Step9 : FinishingThe ARTRestoration
ADVANTAGES OF ART [10]
1) Hand toolsthat are easilyaccessibleandreasonablyaffordablecanbe utilised.
2) A biologicallyfriendlymethodinwhichonlydecalcifiedtoothtissue isremoved,resultinginrelativelytiny
cavitiesandthe preservationof soundtoothtissue.
3) A straightforwardandeasyinfectioncontrol procedure thatdoesnotneedthe use of autoclaved
handpieces.
4) A glassionomerchemical adhesive thateliminatesthe needtocutsoundtooth tissue inordertoretain
restorative material.
LIMITATIONS OF ART [11]
1) There are nolong-termsurvival ratesforglassionomerARTrestorationsandsealants;the longestresearch
publishedsofaristhree years.
2) The technique'sacceptabilitybydental healthcare professionalsisnotguaranteed.
3) The use of hand instrumentsforextendedperiodsof time maycause handfatigue.
4) Hand mixingmayresultina ratherun-standardizedglassionomermix thatvariesacrossoperatorsand
geographical/climaticconditions.
5) The misconceptionthatARTissimple toaccomplish;thisisnotthe case, andeach stepmustbe executed
flawlessly.
6) The technique'sapparentlackof complexity,whichmaymake itdifficultforARTto be easilyacceptedby
the dental profession.
7) The publichas the impressionthatthe newglassionomer"white fillings"are justtemporarydressings.
CONCLUSION
ART isnot a compromise,butrathera wonderful alternativeandbiological therapyoptionforunderdeveloped
nationsandspecificpopulationsinthe developedworld.Itnecessitatesminimumcavitypreparation,which
preservessoundtoothtissue andproduceslessdamage toteeth.The needforlocal anaestheticsisminimised,asis
the psychological damage experiencedbypatients.Handtoolsare readilycleanedanddisinfected,whichsimplifies
infectioncontrol.Because itisasimple operation,the ARTtechniqueisrelativelycosteffective.Itmakesrestorative
therapymore accessible toall populations.

5. ATRAUMATIC RESTORATIVE TREATMENT IN DENTISTRY Review
REFERENCES
1) SobenPeter, Essentials of Public Health Dentistry, 5thEdition.
2) https://www.sciencedirect.com/topics/medicine-and-dentistry/atraumatic-restorative-treatment
3) CM Marya, A Textbookof PublicHealthDentistry,1stEdition
4) https://en.wikipedia.org/wiki/Atraumatic_Restorative_Treatment_(ART)#Background_and_History
5) https://www.semanticscholar.org/paper/Selection-of-restorative-materials-for-the-%28ART%29-a-Yip-
Smales/774adaa99e7a183b46cfd5144f999c1ae653fcd0
6) Garg Y. et al.:AtraumaticRestorative TreatmentinDentistry,International Journal of Oral HealthandMedical
Research| ISSN 2395-7387 | July - August2015 | Vol 2 | Issue 2
7) https://en.wikipedia.org/wiki/Atraumatic_Restorative_Treatment_(ART)#Contraindications
8) SS Hiremath,Textbookof PublicHealthDentistry,3rdEdition
9) CM Marya, A Textbookof PublicHealthDentistry,1stEdition
10) CMMarya, A Textbookof PublicHealthDentistry,1stEdition
11) CMMarya, A Textbookof PublicHealthDentistry,1stEdition