Atraumatic Restorative Treatment for Dental Caries

Atraumatic Restorative treatment for dental consonant CariesAtraumatic restorative treatment for the management of dental caries A Review abstract Atraumatic restorative treatment is a mode of minimal caries intervention that uses only hand instruments. Over the past few old age, there has been an increase in the number of studies reporting on various aspects of the Atraumatic Restorative Treatment and it is oer three decades art has been introduced, so this was considered an appropriate time for a systematic check over on guile. Objective of this appraise article was to assess the effectiveness of artistic production in management of dental caries. All randomized or quasi-randomized control trials on cunning were included. Intervention with adhesive restorative material such as GIC with different viscosity was evaluated. Primary cases measures such as botheration relief, patient discomfort, disturbance and durability of retort was assessed. Studies showed natural selec tion rates ranging from 66% to 76% at 6 twelvemonth for single come forth restorations subterfuge get along provided high selection percentages for single surface restorations and it causes less(prenominal) pain and discomfort.Key words Atraumatic restorative treatment, Survival, Deciduous teeth, Permanent teethIntroductionDental caries is ane of the just about prevalent ad-lib examination diseases of public health concern. It affects almost all told individuals irrespective of age, sex, occupation, religion, castes etc in developed as well as developing countries. It varies greatly among countries, flat within a country and from region to region and there are several reasons for this problem like changes in food habits, poverty, lack of facilities especially to unfortunate section of the society, etc. WHO objective of Health for All still remains a dream, particularly in the underprivileged community of the world. Also, there has been a total change in the methods of treatment of dental disease. We have seen a change in approach of treatment by the dentist, starting with extraction, then conservation of tooth twist and now stress is being laid on preventive dentistry. But the underprivileged tribe have not benefited from these developments that have brought about improved oral health in the industrialized world. Realizing the magnitude of this problem, particularly lack of oral health care in below poverty line segment of society, JE Frencken embarked on simplistic approach of removing caries with hand instruments and filling up the cavity. This approach is termed as Atraumatic Restorative Treatment.1 cheat was first discovered in Tanzania in mid 1980s to suit the needs of the developing countries by JE Frencken Later, in Zimbabwe, the experiment was repeated by his team in larger school population group. WHO endorsed the trick procedure for the underprivileged population on world health day in April 7, 1994.2 The idea of cunning is strongly supported by the advance(a) scientific approach to controlling caries maximal prevention, minimal invasiveness and minimal cavity preparation.3Different studies have been investigating the various aspects of artwork approach in the past and still continue to increase. Most of the studies have investigated the survival of blind restoration and sealants. As ART approach is being utilized all over the world since more than 25 years, there is a need to carry out a systematic investigation about the survival and effectiveness of ART restorations. So the present systematic review focuses on the effectiveness of ART in management of dental caries in deciduous and permanent teeth.Materials and MethodsWe essay to identify all relevant studies. Detailed search strategies were developed for each database to be searched and it was carried out in the Medline, Embase, Hinari, k-hub. All randomized controlled trials or quasi-randomized controlled trials were included. Non-randomized controlle d trials were excluded. Studies with Dentate participants, disregarding of the age and sex, with a history of dental (coronal) caries who have undergone restorative treatment apply either unoriginal restorative or ART approaches were included. Studies in which evaluators were calibrated and independent, Survival result more than 1 year were included. Interventions were adhesive restorative materials, such as GICs with different viscosities, placed with the true Atraumatic Restorative Treatment (ART) approach, including Interim therapeutic restoration (ITR) with hand instruments, compared with different restorative materials, such as amalgam, placed with constituted cavity preparation methods. Studies on modified ART approaches, Survival results Selection of StudiesAll records identified by the searches printed off and checked on the basis of title first, then by abstract or keywords or both. Records that obviously irrelevant were discarded and the full text of all remaining reco rds were obtained. The full reports obtained from all the electronic and other methods of searching assessed independently by ii review authors to establish whether the studies meet the inclusion criteria or not, using an inclusion criteria form, which previously prepared and pilot tested. Where resolution was not possible, a third review author consulted. If more than one publication of a trial was identified, all publications were reviewed and the paper with the first publication date included as a primary quill version. All studies meeting the inclusion criteria then underwent data extraction and a quality assessment.Types of Outcome MeasuresPrimary Outcome MeasurePain relief, i.e. freedom from symptoms of pain and sensitivity as account and experienced by the patient. affected role discomfort during the procedure measured by physiological measurement or behavioral observation.Patients anxiety and stress after treatment.Durability of restoration survival time of restoration ( in months) from the time of placement.secondary winding outcome measuresDefects of restorative materials such as birth, fracture and staining (color changes) of restoration.Restoration failure, e.g. replaced restorations.Marginal integrity of restoration. collateral caries.ResultsPain, solicitude and DiscomfortFive studies were reported on pain out of which three studies suggested that ART was found to be less achy.4,5,6 In a nurture conducted by Rahimtoola S et al7 pain was reported when ART technique was employ but was portentously less than the conventional restorative technique. While in one read there was no significant difference in the pain levels of children treated using conventional restorative treatment, atraumatic restorative treatment or extreme right-winger treatment but it was observe that when conventional restorative treatment was used, more children neededlocal anesthesia.8One study showed that the levels of dental anxiety were less in patients treated wi th ART as compared to conventional restorative treatment.9The studies from Topaloglu et al10 and de Menezes Abreu et al11 reported no difference in the levels of dental anxiety.ART technique has a potential to cause less discomfort to the patient and to less invasive to the dental tissue than conventional approach. The patients credenza of ART was verified by Mickenautsch et al12 who observed that both children and adults receiving ART restorations responded positively to the treatment. Study conducted by Schriks MC13 and Van Amerongen WE14 stated that children treated according to the ART approach using hand instruments alone experience less discomfort than those treated using merry-go-round instrument. Similar findings were reported by ECM Lo CJ Holmgren also.5 A synopsis of these studies outcomes is presented in Table1.TABLE 1 Overview of studies having assessed dental pain, anxiety and discomfort between the ART and the traditional treatment approachComparisonAgeOperator ba ckclothVariable measuredConclusionART vs rotaryInstruments7616 years oldDentistsPain-Questions Did you feelany pain during treatment?ART caused less painART vs rotaryInstruments847 years oldPedodontist specialistPain-WongBaker FACES PainRating shellART caused less painART vs rotaryinstruments vsultraconservativetreatment467 years oldPedodontist specialistPain -WongBaker FACES PainRating Scale-No difference in levels of pain among treatments-Local anaesthesia was morefrequent given in the rotary instrument groupART vs rotaryinstrumentsART vs ART with Carisolv 1067 years oldPedodontist specialistAnxiety-Venham Picture TestNo difference in levels ofanxiety between treatmentsART vs rotaryInstruments9Children and adultsDentists anddental therapistsAnxiety-Childrens fear surveyschedule-Corahs dental anxietyscaleBoth children and adultstreated with the ART wereless dental-anxiousART vs rotaryinstruments vsultraconservativetreatment1167 years oldPedodontist specialistAnxiety-Facial Image S caleNo difference in levels of anxiety among treatmentsART vs rotaryInstruments136-year-old childrenDental studentsand dentistsDiscomfort-Heart rate and modifiedVenham index (observations)ART caused less discomfortDurability of RestorationVarious studies showed that survival rates were lower with increasing full point of time.15,16 Frencken JE15 assessed the survival of ART restoration after first, second and third year evaluation interval and found that the survival rate of one surface ART restoration were higher in first year compared to second and third year.Lo ECM16 Suggested that cumulative survival rates of the large restoration were lower, being 77% and 46% after 3 and 6 year respectively.There were no statistically significant differences in cumulative survival percentages of the evaluated ART restorations between single and multiple-surface restorations at 1-year (p=0.137) and 2-year (p=0.377) evaluations. But at the 10-year evaluation, the survival rate for single-surface restorations (65.2%) was 2.1 times higher than that for the multiple surface restorations (30.6%). This difference was statistically significant (p=0.009).17Secondary Outcome MeasuresDefects of restorative materials wear and fracture of restorationStudies conducted by Lo ECM16 and Frencken JE18 showed that most of the restoration were in good condition and had only minor defects and wear which did not warrant further treatment.Secondary cariesIncrement of secondary caries was found to be maximum in a study conducted by Zanata RL17 while other studies showed no statically significant difference.18,19Operator effect.Frencken JE 18 et al observed an operator effect for single surface ART restorations.It was observed in one study that experienced operators place burst ART restoration than inexperienced operators.15Marginal Integrity of RestorationIn a study the restorations that were evaluated with the USPHS criteria at the 5-year examination, unacceptable marginal integrity, either a bloke extending to the enameldentine junction or the restoration being fractured was found in 9% of the small and 21% of the large restorations.18 While in other study, 63.6% of the ART restorations were assessed as good, 15% as having a slight marginal defect at 3years.19Restoration visitationFailure occurred in 24% of the small restorations and 41% of the large restorations. The large restorations had a higher relative venture of failure, 5.87, compared with the small restorations.16 Failures were related to unacceptable marginal defects and total loss of restoration. Frencken JE 18 reported failure of total 28 ART restorations placed in 25 students during the 3 year period. While same author in another study reported 106 ART restoration failures from total of 487 ART single surface posterior restorations.15DiscussionThe ART approach seems to be an economic and effective method for improving the oral health not only of people in developing but also of those in industrialized countries (Frencken and Holmgren 2004).1 It may be considered as a safe and conservative alternative for conventional restorative dental treatment, particularly for Class I (occlusal) dental cavities.Pr imary outcome measuresPain, Discomfort and AnxietyThe originators of the ART approach noticed that the technique had a potential to cause less discomfort to the patient and to be less invasive to the dental tissues than the conventional approach. The patients acceptance of ART was verified by Mickenautsch and Rudolph12, who observed that both children and adults receiving ART restorations responded very positively to the treatment. Dentists also seemed to approve the new approach. Among the main reasons given were those related to the patients comfort the reduced use of local anesthetic and absence of the noisy drill and suction.20Some suggested that ART as found to be less painful and cause less dental anxiety. The reasons could be contributed to the operators level of specializati on and /or skills in handling anxious children. The studies from Topaloglu et al 10 and de Menezes Abreu et al 4,11 in which no difference in levels of dental anxiety and dental pain were observed, were performed by pediatric dentists. In the studies that favored ART 7,8,13 all operators, but the one from de Menezes Abreu et al, 8 were non-pediatric dentists (general practitioners, dental therapists or dental students). However, the latter study had included children younger than 6 years, and all those given the conventional treatment received local anesthesia and the restorations were performed under rubber dam isolation. It is not unrealistic to argue that age and the use of the needle and that of rubber dam might have influenced childrens perception of pain. In light of all these aspects, it can be hypothesized that the behavior management provided by a pediatric dentist may overcome much of the discomfort that a child can feel independent of the restorative treatment approach.Du rability of RestorationThe survival percentages of single surface non occlusal posterior ART restoration were significantly higher than for equal amalgam restoration 4.4, 5.3 and 6.3 years. Although it is known that non occlusal glass ionomer restoration survive long but significant lower survival results for non occlusal amalgam than for comparable ART glass ionomer restorations were observed.15The cumulative survival rate of ART single surface restoration remained high throughout the study 92.7% (SE 3.0%) over 2 years and65.2%(SE 7.3%) up to 10 years. These rates are in the line with the results of other investigations, which reported survival rates ranging from 66% to 76% at 6 year for single surface restorations. The cumulative success of 65.2% observed in this study could be considered even better due to the longer period of clinical service. The survival rates of multiple surface restorations (class II) decreased significantly from 2 to 10 years. After 2 years, the survival rates between single and multiple surface restorations were similar. These results are consistent with those of Cefaly and Farag which observed similar survival rates for class 1 and class II restoration after 1 and 5 years, respectively. However, a statistical difference was apparent over the 10 year evaluation period (65.230.6% success rates for single and multiple surface restorations, respectively).17Secondary outcome measuresDefects of restorative material such as Wear, Fracture and Staining of RestorationThe annual wear rate of the high strength glassionomer material used in their study was rather stable at around 20-25 m after the first year and this did not increase much with time or size of the restoration. This rate is very satisfactory and may help to alleviate near of the concerns of earlier reviews on ART. The use of an adhesive material in ART restorations also makes repair of restorations with gross defects and wear possible and total replacement may not be necessary .15 Reasons for minor defects and wear can be explained by the fact that firm finger pressure was applied over the restorative material to ensure good penetration of glass ionomer into the pits and fissures, as recently demonstrated.18Secondary cariesIt has been shown that caries left in occlusal enamel lesions had either not progressed at all or only progressed slightly under clinically intact as well as sometimes intact sealants after 3 years. In contrast, caries had progressed under sealants that were never intact.18No ART restoration failed because of carious lesion development only. Restorations failed because of a combination of dentine carious lesions and mechanical defects.17 This pattern of failure was also observed by Frencken et al15 but contrasts with the study of Prakki et al21 which observed no caries even in those teeth whose ART restorations were missing.Operator effectAn operator effect has been cited in a number of ART studies.18,22,23 Although all operators (dent ists and dental therapists) in the studies referred to above had followed a training course on ART, the operator effect seems to indicate that in order to perform quality ART restorations, the operating dental personnel requires skill, diligence and comprehension. An ART training course of a couple of days may be too short for some qualified dentists and dental therapists.15 The operators greater experience in applying ART and the use of a high-viscous glass ionomer in the study may explain the higher results.18Failure of RestorationThe finding that failures of ART restorations placed in the same child were correlated suggests that some factors related to the individual subjects such as diet, occlusion, and caries risk may influence restoration survival.16 The predominant reasons for ART restorations to fail were unacceptable defects at the margin and re restoration.15Almost half of the failures were related both to the natural characteristics of the glass ionomer used and to the o perators handling of the material. Few failures were due to excessive wear. The other half of the failures were considered to be operator related. The exact reasons for the unacceptable marginal defects were unknown. However, it can be speculated that improper mixing of glass ionomer, providing a mixture that was either too dry or too wet, was one of the reasons. Another reason could be the hindrance in inserting the material into the depths of deep and small preparations. Subsurface voids produced during insertion may have resulted in later fracture of the surface layer under pressure.18Compared to conventional treatment approaches, ART is still very young. Despite this, much progress has been made in researching various aspects of the ART approach. More experience in the existing technique of cleaning carious cavities with hand instruments has been gained and newer, physically stronger glass ionomers have been marketed as a result of its existence. These developments have most pr obably led to the higher survival results of ART restorations in permanent teeth in the more recent compared to the early studies.ConclusionART technique has proved to be less painful and causes less discomfort to the patients with high survival rate in both in primary and permanent teeth. This technique has the potential to make oral health care more available to a larger part of the worlds population than onward. The greater part of the worlds population has no access to restorative dental care. ART should be taken seriously by the dental profession and educational courses should be organized before the approach is used in the clinic.