DEPARTMENT OF PUBLIC

HEALTH DENTISTRY

ATRAUMATIC RESTORATIVE TREATMENT(ART)

GUIDED BY - Dr. Gaurav Gupta

Dr. Saurav Gupta SUBMITTED BY –Ananya
Saxena
BDS III
YEAR
 INDEX
 Introduction
 History
 Definition
 Goals
 Principles
 Reasons for using hand instruments
 Reasons for using glass ionomer
 Indications
 Contraindications
 Advantages
 Materials and armamentarium used
 Procedure
 - 1. arrange a good environment
 Operators posture
 Assistance
 Patients position
 Patients head position
 2. hygiene and control of cross infection
 3. restoring the cavity
 Caries removal
 Conditioning the prepared cavity
 Mixing the material
 Things to remember
 Restoring the cavity
 Failed or defective restorations
 Survival rate
 ITR AND ART
 Conclusion
 INTRODUCTION
 Atraumatic Restorative Treatment (ART),is
based upon removing decalcified tooth tissues
using only hand instruments and restoring the
cavity with an adhesive filling material.
 A minimally invasive approach to both prevent
dental carious lesions and stops its further
progression.
 The technique of ART was pioneered in
Tanzania in the mid 1980’s – Jo Frencken.
 DEFNITION
 The American Academy of Paediatric Dentistry
( AAPD) defines ART as “ a dental caries
treatment procedure involving the removal of
soft , demineralised tooth tissues using hand
instrument alone, followed by restoration of
the tooth with an adhesive restorative material,
routinely glass ionomer”.
 PRINCIPLES
 . Based on the modern principles of :
 Minimal intervention

 Minimal invasion

 Minimal cavity preparation

 The two main Principles of ART are:

 Removing carious tooth tissues using hand instruments

only.

 Restoring the cavity with a restorative material that sticks to

the tooth
 REASONS FOR USING HAND
INSTRUMENTS
 Use of biological approach ,which requires
minimal cavity preparation that conserves sound
tooth tissues and causes less trauma to the teeth.
 It is cost effective as compared to electrically
driven dental equipment.
 Limitation of pain that reduces the need for local
anesthesia.
 Infection control.
 REASONS FOR USING GLASS
IONOMER CEMENT
 As the glass –ionomer bonds chemically to
both enamel and to dentin.
 Fluoride is released from the restoration –
Anticariogenic.
 It is similar to oral hard tissue and is non
irritant to oral soft tissues.
 INDICATIONS
 ART is carried out –
 Only in small cavities ( involving dentin)
 Cavity accessible to hand instruments.
 Introducing oral care to very young children.
 For patients with extreme Fear and anxiety.
 For home bound and elderly and those in
nursing homes.
 For Mentally and physically challenged.
 CONTRAINDICATIONS
 There is presence of swelling or fistula near
the carious tooth.
 Near the carious tooth
 - the pulp of the tooth is exposed
 -teeth have been painful for a long time and
there may be chronic inflammation of pulp.
 - there is an obvious carious cavity, but the
opening is inaccessible to hand instrument
 ADVANTAGES
 ART is a biological approach that require
minimal cavity preparation that helps in
conserving sound tooth structure.
 ART is painless
 Simplifies infection control
 ART is cost effective
 ART can be easily done even in remote areas
 ART is a simple technique , that can be done
by both by well trained dental professional as
well as by a primary health care worker.
 ART can be administered easily in children as
well , fearful adults ,physically and mentally
challenged persons and in elderly patients too.
 It makes restoration more accessible for all
population groups.
MATERIALS AND ARAMAMENTARIUM
REQUIRED
PROCEDURE
 1.ARRANGE A GOOD WORKING
ENVIROMENT
 OUTSIDE THE MOUTH –
 The correct positioning of both the operator and
patient is essential to achieve good quality care.
 Operators work posture and position :
 - work posture and position of both the operator
should be as such that should provide the best view
of the patient's mouth.
 Both should be comfortable
 The direct rear position i.e., at 12 o’ clock and
the right rear position i.e., at 10 o’clock are the
most commonly used positions
 ASSISTANCE

The assistant works on the left side of a right handed operator

and does not change its position.
Patient should lie in supine position
 PATIENT’S HEAD POSITION
 Patient can assist the operator by tilting ,
turning the head and by opening the mouth
wide enough for better access.
A.Tilting the head
B. Turning the head
 C. Mouth opening
 Fully open
 Partially closed
 OPERATING LIGHT
 Light source can be natural as well as
artificial .
 In a field portable light source is recommended
e.g., headlamp , glasses with light source
attached or a light attached to mouth mirror
Loupes with light

Mouth mirror fitted with light

 INSIDE THE MOUTH
 Control of saliva plays a vital role in the
treatment.
 Cotton wool rolls are used , as they are quite
effective is providing a moisture free
operating field.
 2. HYGIENE AND CONTROL OF CROSS
INFECTION
 Always wear gloves and mask
 Cleaning and disinfection of the working place
and sterilization of instruments.
 Place all instruments in water immediately
after use.
 Remove all debris from the instrument by
scrubbing with brush in soap water.
 If an autoclave is available, follow
manufacture’s instruction carefully.
 If a pressure cooker is available, prepare fire using the
fuel available – wood , gas , charcoal, solar energy.
 Put the clean instruments in the pressure cooker and add
clean water up to a depth of 2-3 cm from the bottom and
boil them for 15 minutes and then remove it from fire .
 Let them cool down properly before use .
 Use instrument forceps to remove them and then dry them
out on a dry clean towel.
 Store them in a covered, preferably, metal box.
 3. RESTORING THE CAVITY
 Start by pacing the cotton wool rolls alongside
the tooth to be treated.
 It helps in keeping the the field dry.
 Remove the plaque from the tooth surface with
a wet cotton pellet ,then dry it.
 CARIES REMOVAL
 Soft caries is removed using the excavator by
making circular scooping movements- like
using a spoon .
 If the cavity opening in enamel 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 in dry conditions , therefore
change the saturated cotton wools for dry ones.
 Carious dentine is removed with excavator by
making circular scooping movements around
the long axes of the instruments.
 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.
 Be cautious while removing the carious dentin from
two places in the cavity :

 I. the enamel – dentin junction

 II. the floor in deep cavities
 I. Enamel – dentin junction -This part of the dentin
is close to the surface of the tooth.
 It is the place where the restoration has to stick .
 If caries is not removed properly , a good join will
be hard attain .
 This may even make bacteria to penetrate between
restoration and cavity wall and caries will develop
further.
 II. Floor in deep cavities
 When removing the carious dentin near the
pulp there is risk of damaging or exposing the
pulp.
 Remove no more then required portion in the
deeper portion of cavities .

 After the caries is removed , clean it with wet

cotton wool .
 CONDITIONING THE PREPARED
CAVITY
 In order to improve the chemical bonding the
tooth structures , the cavity walls must be clean
.
 It is done using a chemical solvent namely :
 i . A dentine conditioner or tooth cleaner
 ii. The liquid supplied with gic itself .
 Dentin conditioner is usually a 10% solution of
poly acrylic acid
 Glass ionomer liquid can be also used for
cleaning the cavity if it contains the same acid
as is used in for conditioning.
 Liquid is too strong and needs to be diluted
first .
 It is applied with the help of cotton wool pellet .
 If the cavity is contaminated with blood , stop
the bleeding by pressing it with cotton wool
pellet on the wound.
 Wash it and then make it dry and recondition it .
 MIXING THE MATERIAL

 Follow the instruction according to the

manufacturer .
 Place a scoop of the powder on a mixing pad .
 Use the spatula to divide the powder into two equal
parts , and then put a drop of liquid next to the powder.
 spread liquid on the mixing pad with the spatula and
start mixing by adding one half portion of the powder
into the liquid.

 As soon as the powder particles are wetted the second

portion of the powder is included into the mixture .
 Mixing should be completed within 20-30 secs .
 Final mixture should look smooth , glossy and putty
type.
 RESTORING THE CAVITY
 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 procedure must be completed within 30-
40 seconds.
 A perfectly restored cavity
 FAILED OR DEFECTIVE RESTORATION
 A restoration may not be acceptable or unsatisfactory if,:
 i.Restoration is completely missing
 Some of the reasons for failure could be :
 Contamination with saliva or blood during the
procedure,
 Mix of material was too wet or to dry
 Not all the soft caries had been removed,
 Thin undermined enamel had been left behind, and this
later broke off.
 Treatment-
 Clean the cavity completely , apply dentin conditioner
and refill it .
 ii. 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
placement of the restoration .
 Treatment –
 Clean the tooth surface and /or remaining restorative
material with an explorer or small excavator and wet
cotton wool pellets
 Condition the entire surface and material.
 Fill in the gap with new mixture and ensure it is no too
high.
 iii. The restoration has fractured
 This most commonly happens in a multiple
surface restoration which is 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 .
 If the fractured part cannot be removed then
ART cannot be done , and traditional treatment
is done.
 Possible reasons for this are
iv. The restoration has worn away

 The patient eats very hard food frequently

 The patient clenches his/her teeth frequently
 The mixture had been too dry or wet.
 Treatment –
 Ensure that all the surfaces of the tooth and the
reaming restoration are clean.
 Apply dentin conditioner over the glass ionomer
and the cavity walls.
 Place a new layer of glass ionomer over the old
one and finish the restoration.
 v. Caries has developed in the adjacent or
surface .
Remove the soft caries .
After all decay has been removed , clean and fill the
new cavity adjacent to the restoration according to
the standard procedure
 SURVIVAL RATE
 Survival rate of restoration done using ART
vary depending on several factors.
 In a meta analyses have shown the survival
rate of ART restorations, single surface
restorations were found to be more successful
than multi –surface restorations in both
primary and permanent dentition.
 High viscosity glass ionomer was retained
longer than medium viscosity.
 ITR AND ART
 Interim therapeutic restorations (ITR) and
atraumatic/alternative restorative technique
(ART) have similar techniques and materials
but different goals.
 ITR may be used in very young patients ,
uncooperative patients , or patients with
special health care needs whom traditional
cavity preparation and/or placement of
traditional dental restoration are not feasible .
 CONCLUSION
 The ART procedure has been developed to
focus on developing countries of people who
are unable to obtain restorative dental care .
 ART is a combined preventive and curative
oral care procedure which must be
administered along with health promoting
messages about a prudent diet, good oral
hygiene , use of fluoride toothpaste and sealant
application.
THANK YOU