3. Need -World Health Organization (WHO).
The ART was developed in Tanzania (mid-1980s)
ART-minimal intervention and maximal prevention
INTRODUCTION
4. • Mid-1980s: Tanzania community-based primary oral health program by
Universityof Dar es Salaam
• 1986: The results of the pilot study were presented at the scientific meeting of
the Tanzanian Dental Association in 1986, and a minimal intervention
approach, later called ART, was officially born.
5. DEFINITION
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”.
6. Alternative restorative treatment
• Modified- use of rotary instruments.
• Slow-speed rotary instrument- enhance cavity preparation and
restorative retention.
• Endorsed by the WHO(2004) and the International Association for Dental
Research
8. • The two main principles of ARTare:
• Removing the carious lesionsusing
hand instruments.
• Restoring the cavity with arestorative
material that sticks to thetooth.
ART is mainly performed using glass-ionomer as
the restorative material.
9. Thereasons forusing glass-ionomerare:
- as the glass-ionomer –chemical adhesion- less
tooth preparation,
- fluoride released
- it is similar to hard oral tissues -biocompatible
For these reasons, ART provides preventive and
curative treatment in oneprocedure.
10. small and shallow cavities (involving the
dentin) that are accessible to hand
instruments.
Introducing oral care to very young
children, not previously exposed todentistry.
For patients with extremefear/anxiety.
10
11. Inaccesible elective dental treatment
For mentally and/or physically handicappedpatients.
In high-risk caries cases, as an intermediate treatment, to
stabilize conditions.
12.
13. Contraindication
There is presence of swelling (abscess) or fistula (opening
from abscess to the oralcavity)
near the carioustooth,
- the pulp of the tooth isexposed,
- chronic inflammation of thepulp.
14. - there is an obvious carious cavity but the openingis inaccessible
to hand instruments,
example in a proximal surface, but the cavity cannot be entered from
the proximal nor the occlusaldirections.
15. Operators position
sit firmly on the stool,
straight back,
thighs parallel to the floor and
both feet flat on thefloor.
operator able to see the patient’s
teethclearly.
18. Patient’s head position
- Backward tilt lifting thechin foraccess to upperteeth.(a)
- Forward tiltdropping thechin foraccess to lower teeth.(b)
19. Range of positions : 10 to 1 on theclock.
Most commonly usedpositions:
• direct rear position(12 o'clock) and
• right rear position (10o'clock)
20. RIGHT FRONT POSITION (7 O'CLOCK)
1. WORKING AREAS INCLUDE:
a) MANDIBULAR ANTERIOR
b) MANDIBULAR POSTERIOR
TEETH (RIGHT SIDE)
c) MAXILLARY ANTERIOR TEETH
21. RIGHT POSITION (9 O'CLOCK)
WORKING AREAS INCLUDE:
a) FACIAL SURFACES OF
MAXILLARY RIGHT POSTERIOR
TEETH
b) FACIAL SURFACES OF
RIGHT
MANDIBULAR
POSTERIOR TEETH
OF
RIGHT
c) OCCLUSAL SURFACES
MANDIBULAR
POSTERIOR TEETH.
21
22. RIGHT REAR POSITION (11 O'CLOCK)
MOST AREAS OF MOUTH ARE ACCESSIBLE FROM
THIS POSITION EITHER USING DIRECT OR
INDIRECT VISION
WORKING AREAS INCLUDE:
a) PALATAL AND INCISAL (OCCLUSAL)
SURFACES OF MAXILLARY TEETH
b) MANDIBULAR TEETH (DIRECT VISION).
23. DIRECT REAR POSITION (12 O'CLOCK)
1. WORKING AREAS ARE LINGUAL
SURFACES OF MANDIBULAR TEETH.
23
25. PAIR OF TWEEZERS
•Carry cotton wool,
rolls, pellets,
wedges, and
articulating paper.
SPOON EXCATATOR
•Used for removingsoft
carious lesions.
•Small- diameteris
about 1mm.
•Medium- diameteris about
1.5 mm.
26. DENTAL HATCHET
•Use for widening
the entrance tothe
cavity.
APPLIER/CARVER
•Used forinserting the
mixed GIC intocavity.
•Toremoveexcess
restorative materials.
27. MIXING PADAND
SPATULA
•Mixing GICc
OPERATING LIGHT
The light source can be
natural orartificial.
Artificial light : more
reliable, constant and can also
be focused on a particular
spot.
In a field setting a portable
light source is recommended
e.g. headlamp.
2/27/2016 25
29. PETROLEUM JELLY
•Use to keepmoisture
away from theGIC
• Prevent sticking
of gloves to the
GIC
PLASTIC STRIP
• Use for contouring
the proximal surface
of multiple- surface
restoration
30. WEDGES •Use to hold theplastic
stripsclose
GIC
•Supplied as apowder
and liquid.
31. Others are :
Examination gloves
Mouth mask
Operation bed/ headrest extension stool
Methylated alcohol
Pressure cooker
Instrument forceps
Soap and towel
Sheet of textile
Sharpening stone
32. 1.
For teeth in the lowerjaw Fo2
r/
2
t7
e/
2
e0
t1
h6
in the upperjaw
43. 1.Moisture control- cotton wool rolls.
2. Prepare cavity.
3.Place a plastic strip between the teeth -
proximal surface.
4.Insert a soft wood -keep the plastic
strip firmly in position.
44. 5.Condition the cavity.
6.Mix the GIC- insert it into the cavity slightlyoverfilled.
7. Adapt contour using mylar strip.
8.Remove the strip and wedge, and cover the restoration with
petroleum jelly.
9.Remove any excess material with the carver, check the bite
with articulation paper and apply another coat of
petroleum jelly.
10. Remove cotton wool rolls.
11. Ask the patient not toeat forone hour.
46. be sterilized after they have been
Instruments should
sharpened.
Correct and incorrect position of
dental hatchet for sharpening.
Instrument must be held parallel
to the f lat surface of the
sharpening stone.
48. If available, always wear gloves.
Cleaning and disinfection of the working place
Sterilization of instruments
49. • No restoration or sealant, irrespective of the material used, lasts forever.
• First clinical evaluation - after half a year.
• Further evaluations : on an annual or biannual basis depending on
expected caries development, and other risk factors
50. If the surface is hard, leave it alone.
If the surface is carious, reseal or make a small restoration
depending on the extent of the defective sealant or of the
caries present.
51. 1.it is completely missing,
2.a large part of it has broken away,
3.the restoration is fractured,
4.much of the restorative material has worn away,
5.caries has developed at the restoration margin or
elsewhere on the tooth surface.
Whatever the reason, clean the cavity
completely, apply dentine conditioner and refill
the cavity according to the description .
52. Use of easily available and relatively inexpensive
A biologically friendly approach
The limitation of pain- minimizing the need for local
anesthesia.
A straight forward and simple infection control
53. The chemical adhesion
Fluoride release.
The combination of a preventive and restorative treatment in
one appointment.
54. The restoration can be easily repaired if damaged.
Low cost
Restore and prevent caries in young patient, uncooperative
patients, or patients with special health care needs or when
traditional cavity preparation and/or placement of traditional
dental restoration is not feasible.
ART restoration can help maintain a natural tooth eruption
pattern and avoid disturbances in the position of permanent
teeth.
55. Long-term survival rates for glass-ionomer ART restorations and
sealants are not available.
Use limited to small- and medium-sized, one-surface lesions because
of low wear resistance and strength of existing glass ionomer
materials.
Hand mixing might produce an improper mix , varying among
operators.
Misapprehension that can ART can be performed easily-this is not the
case and each step must be carried out to perfection.
Possibility exists for hand fatigue from the use of hand instruments
over long periods.
57. Types of Preventive Resin Restoration
• There are three types of preventive resin restorations based on the
extent and depth of the carious lesion.
1. Type A
2. Type B
3. Type C
58. • Type A: Comprises of suspicious pits and fissures where caries is
limited to enamel. A slow-speed round bur is used to remove any
decalcified enamel.
• Type B: Comprises of incipient lesion extending into dentin that is
small and confined.
• Type C: Is characterized by the 'presence of deep caries and need
for greater exploratory preparation in dentin.
59. Advantages of Preventive Resin Restoration:
1. Minimal cavity preparation is required, thus preventing unnecessary
removal of healthy tooth structure for retention.
2.Seals caries thereby halting the destruction of tooth, e,g teeth with pit
and fissure, dens evaginatus.
3.Loss of the restoration and subsequent replacement proves to be less
invasive than that for conventional restoration like amalgam.
61. Type A:
Steps involved :
• 1. The surface is cleaned.
• 2. Cotton rolls or, preferably, a rubber dam is used for isolation
• 3. Decalcified pits and fissures are removed with a slow speed round
bur.
• 4. Acid etching gel is placed over the entire occlusal surface for 60
seconds.
62. • 5. It is then washed for 20 seconds and dried for 10 seconds.
• 6. The sealant is applied carefully, avoiding air entrapment in the preparation site.
• 7. It is polymerized with the visible light for 20 seconds.
• 8. The occlusion is adjusted, if needed, with finishing bur.
63. Type B:
Steps involved:
• 1. Thorough prophylaxis of the surface.
• 2. Placement of a rubber dam.
• 3. Carious pits and fissures are removed with a slow speed round bur.
• 4. Fast setting calcium hydroxide is placed over the exposed dentin.
• S. Acid etching gel is placed over the entire occlusal surface for 60 seconds.
64. • 6. It is then washed for 20 seconds and dried for 10 seconds.
• 7. A coat of bonding agent is applied on the walls of the preparation.
• 8. The preparation is then filled with composite resin material.
• 9. The filled sealant material is applied over the entire occlusal surface and all layers
are simultaneous light cured.
• 10. Occlusion is adjusted and the surface is finish and polished
65. Type C:
• 1.Thorough prophylaxis of the surface.
• 2. Placement of a rubber dam.
• 3. Carious pits and fissures are removed with a slow speed round bur.
Since it involves deep caries, local anesthesia may be required.
• 4. A bevel is placed on the enamel cavosurface margin of the preparation.
• 5. Fast setting calcium hydroxide is placed over the exposed dentin.
66. • 6. Acid etching gel is placed over the entire occlusal surface for 60 seconds.
• 7. It is then washed for 20 seconds and dried for 10 seconds.
• 8. A coat of bonding agent is applied on the walls of the preparation.
• 9. The preparation is then filled with composite resin material.
• 10. The filled sealant material is applied over the entire occlusal surface and
all layers are simultaneously light cured.
• 11. Occlusion is adjusted and the surface is finished and polished
Editor's Notes
In many countries, the caries process frequently progresses beyond the reversible stage and many people believe that loss of teeth is part of life. The main method of treating dental caries is extraction. The need to develop a new approach to oral care for use in economically less developed regions was reinforced by the World Health Organization (WHO). The ART was developed in Tanzania in mid-1980s as part of a community-based primary oral health program. The ART approach is based on minimal intervention and maximal prevention retaining sound tooth tissues
The reasons for using glass-ionomer are:
as the glass-ionomer sticks chemically to both enamel and dentine, the need to cut sound tooth tissue to prepare cavity is reduced,
fluoride is released from the restoration to prevent and arrest caries and,
it is rather similar to hard oral tissues and does not inflame the pulp or gingiva.
In general ART is carried out only in the small and shallow cavities (involving the dentine ) that are accessible to hand instruments.
Introducing oral care to very young children, not
previously exposed to dentistry.
For patients with extreme fear/anxiety.
teeth have been painful for a long time and there may be chronic inflammation of the pulp.
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 height of the stool should be adjusted so that the operator can see the patient’s teeth clearly.
The distance from the operator’s eye to patient’s tooth
is usually between 30 and 35 cm. The operator should
be positioned behind the head of the patient
Oral care is best provided by a team consisting of an operator and an assistant. However, assistance may not always be available. The assistance works at the left side of a right-handed operator and does not change position.
as close as possible facing patient mouth head- 10-15 cm higher
The patient should lie on a flat surface that will provide safe and secure body support and a comfortable and stable position for lengthy periods of time
FOR BETTER UNDERSTANDING, SITTING POSITIONS OF OPERATOR ARE RELATED TO A CLOCK. IN THIS CLOCK CONCEPT, AN IMAGINARY CIRCLE IS DRAWN OVER THE DENTAL CHAIR, KEEPING THE PATIENT'S HEAD AT THE CENTER OF THE CIRCLE.
THEN THE NUMBERING TO CIRCLE IS GIVEN SIMILAR TO A CLOCK WITH THE TOP OF THE CIRCLE AT 12 O'CLOCK.
ACCORDINGLY THE OPERATOR'S POSITIONS
(RIGHT HANDED OPERATOR)
7 O'CLOCK, 9 O'CLOCK, 11 O'CLOCK, AND 12 O'CLOCK
LEFT HANDED ,
5 O'CLOCK, 3 O'CLOCK AND 1 O'CLOCK .
INCREASE THE EASE AND VISIBILITY, THE PATIENT'S HEAD MAY BE TURNED TOWARDS THE OPERATOR.
Dentist sit right to the patient
IN THIS POSITION, DENTIST SITS BEHIND AND SLIGHTLY TO THE RIGHT OF THE PATIENT AND THE LEFT ARM IS POSITIONED AROUND PATIENT'S HEAD
DENTIST SITS DIRECTLY BEHIND THE PATIENT AND LOOKS DOWN OVER THE PATIENT'S HEAD DURING PROCEDURE.
Clinical Characteristics of gic
bonds chemically provides a good cavity seal.
Fluoride release
Glass-ionomer is biocompatible
An important aspect for the success of ART is the 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.
– Upper Teeth: Retract the lip and cheek with the mouth mirror to make space between the cheek and teeth for the cotton wool roll. Place the cotton roll in position with a slight rotating action from the tooth towards the gingiva. This will help prevent the cotton wool roll from coming out easily.
Lower Teeth: Ask the patient to stick the tongue out. Push the tongue aside with the mouth mirror. Place a cotton wool roll on each side of the floor of the mouth. Then ask the patient to retract the tongue back to its normal position.
Remove plaque from the tooth surface with a wet cotton wool pellet, and then dry the surface with a dry pellet.
Soft caries is removed using the excavator by making circular scooping movements - like using a spoon.
If the opening of the hole is narrow, widen the entrance of the cavity by placing the blade of the dental hatchet into the cavity and turning the instrument forward and backward like turning a key in a lock
Excavation is easy to do when the tooth is dry. Therefore, change saturated cotton wools for dry ones.
Carious dentine is removed with excavator by making circular scooping movements around the long axes of the instrument.
Overhanging enamel must be removed with the blade of the dental hatchet. Place the instrument at the edge of the enamel and fracture off small pieces.
After all the caries is removed from the cavity, it is cleaned with wet cotton wool
In order to improve the chemical bonding of glass-ionomer to the tooth structures, the cavity walls must be very clean. It is not effective to do this with wet cotton wool pellets and therefore a chemical solvent is used. There are two possibilities:
The dentine conditioner is usually a 10% solution of polyacrylic acid. Apply one drop of the conditioner on a pad or the slab. Dip a cotton wool pellet in the drop and then clean the entire cavity and adjacent fissures for 10-15 seconds. Do this holding the cotton wool pellets with a pair of tweezers. Then, immediately, wash the cavity and fissures at least twice with cotton wool pellets, dipped in clean water.
GC Cavity Conditioner is a bond surface conditioner with 20% polyacrylic acid and 3% aluminum chloride hexahydrate. This agent conditions and cleans the bonding surface of the tooth before using glass ionomer restoratives, bases, liners or core buildup materials. It should not be used with Fuji I Luting Cement. Removes smear layer and debris for improved bonding
Seals dentin tubules to eliminate sensitivity
Thin viscosity to control placement
Deep blue tint allows for easy visibility
The glass-ionomer liquid can be used for cleaning the cavity if it contains the same acid as is used for conditioning. Usually the liquid is too strong and needs to be diluted. This is done by placing one drop of liquid on a pad or slab. Then moisten a cotton wool pellet by dipping it in water.
It is advisable to dispense one drop for conditioning and a second drop for mixing,
keeping the bottle in the vertical position between dispensing.
The material used for restoring cavities and sealing pits and fissures is glass-ionomer. This material must be used correctly for achieving good results.
Tapping the bottle prior to use will ensure that the powder particle is not compacted.
Make sure that the spoon is full, & no excess powder on back of spoon or handle
scrape the top of spoon over the lip on the bottle
tip the bottle to its side first & allow the liquid to run into the spout
- powder is divided into 2 equal halves.
-the first half is incorporated into the liquid & mixed by folding technique within 10-15 secs.
-then incorporate the 2nd half within next 15 secs.
- do not spread the mix widely around the slab & do not spatulate heavily.
After mixing for 10 secs , use a dental probe or small ball-ended instrument , touch the top of the pile and lift the cement up.
It should string up 2cm or 3cm from the top, then break away the slump back to its original shape, & glossy appearance.
A glossy mix attained indicates the presence of poly acid, which will take part in adhesion.
Insertion of the mixture into the prepared cavity and over the remaining fissures must begin immediately. Use the applier/carver to place small amounts of the mixture into the cavity. This technique will avoid air being trapped between the floor of the cavity and the glass-ionomer (voids). The entire application procedure must be completed within 30-40 seconds.
press-finger technique to place the material into the cavity, which leads to what is called a sealant-restoration. This occurs because by using the finger to press down the HVGIC, it will penetrate the cavity and some excess will spread along the cavity margins and over the pits and fissures, sealing both areas. This action is considered to produce the extra-preventive effect provided by this approach.
The excess material is removed with a carver.
Cover the ART restoration with a new
layer of petroleum jelly
The patient is not allowed to eat for at least 1 hour.
Place a plastic strip between the teeth and use this to make the correct tooth contour of the proximal surface.
Insert a soft wood wedge between the teeth just at the gum margin to keep the plastic strip firmly in position.
Hold the strip tightly with the index finger on the palatal side of the tooth. Wrap the strip firmly around to the buccal side to adapt the restorative material well into the cavity. Hold the strip with the thumb on the buccal side for 1-2 minutes until the material has set firmly
Hand instruments used for cutting hard tooth tissues, the excavator, dental hatchet and carver, must be sharp to be effective.
A blunt instrument is a definite hazard, as it requires excessive force to cut enamel and dentine. The sharpness of the cutting edge can be tested effectively on the thumbnail. If the cutting edge digs in during an attempt to slide the instrument over the thumbnail, the instrument is sharp. If it slides, the instrument is blunt. Only light pressure is exerted in testing for sharpness.
Sharpening the Dental Hatchet and Carver
A special flat stone, for example an 'Arkansas' stone, is used for sharpening the hatchet, carver and spoon excavator. The procedure to follow is described below step-by-step.
Place the flat sharpening stone on a table.
Put a drop of oil on the stone.
Hold the stone firmly with one hand and rest the middle finger of the other hand on the stone as a guide.
Position the cutting edge of the hatchet or carver in the oil parallel to the surface of the stone .
Slide the instrument back and forth over the stone several times for maximum sharpness. Take care that the surface to be sharpened stays parallel to the stone surface.
Sharpening Spoon Excavator
Place the round surface of the excavator in the oil and make small strokes from the center of the round surface to the edge of the spoon Do this in all directions so that the entire cutting edge is sharpened.
If available, always wear gloves.
Cleaning and disinfection of the working place and sterilization of instruments is essential to prevent infection passing from operator to patients and vice versa or between patients via the operator.
Cleaning and disinfection of surfaces in the working place can be done by using cotton gauzes impregnated with methyl spirit (alcohol).
In a clinic, instruments can be sterilized in an autoclave or a pressure cooker. If not in the clinic, a pressure cooker or a pan with a lid to boil the instruments can be used.
To avoid the risk of infection with diseases such as HIV) and hepatitis B virus (HBV), all instruments must be sterilized before being used for each patient.
Examine the tooth carefully for signs of caries
Use of easily available and relatively inexpensive hand instrument rather than expensive electrically driven dental equipment.
A biologically friendly approach involving the removal of only decalcified tooth tissue which result in relatively small cavities and conserve sound tooth structure.
The limitation of pain ,thereby minimizing the need for local anesthesia.
The chemical adhesion of GIC reduces the need to cut sound tooth tissue for retention of the restorative material.
The leaching of fluoride from GIC prevent secondary caries development and probably re mineralizes carious dentine.
The combination of a preventive and restorative treatment in
one appointment.
ART may be used to restore and prevent caries in young patient, uncooperative patients, or patients with special health care needs or when traditional cavity preparation and/or placement of traditional dental restoration is not feasible.
ART restoration can help maintain a natural tooth eruption pattern and avoid disturbances in the position of permanent teeth.
Simonsen, who terms this technique preventive resin restoration, recommends it for restoring carious lesions at the early stages with removal of minimal tooth structure, while simultaneously protecting unprepared areas from later caries attack.
This restoration combines the preventive approach of sealing susceptible pits and fissures with conservative cavity preparation of caries occurring on the same occlusal surface. Instead of the traditional amalgam cavity preparation's "extension for prevention" beyond the area of decay into the adjacent pits and fissures, the CAR or PRR limits cavity preparation to the discrete areas of decay
Comprises of suspicious pits and fissures where caries is limited to enamel. A slow-speed round bur is used to remove any decalcified enamel
Comprises of incipient lesion extending into dentin that is small and confined.
Is characterized by the 'presence of deep caries and need for greater exploratory preparation in dentin.
