Effectiveness of Single-surface ART Restorations in the Permanent Dentition: A Meta-analysis

Micro-mechanical bond strength tests for the assessment of the adhesion of GIC to dentine

BACKGROUND

The aim of this study is to critically evaluate the bond strength (BS) of Glass-Ionomer Cements (GIC) to dentine with microtensile (μTBS) and microshear (μSBS) BS tests by assessing their rankings and failure patterns.

METHODS

Samples were made on flat dentine surfaces and submitted to μTBS and μSBS. The materials used were: high viscosity GIC (Ketac™ Molar Aplicap-KM), resin-modified GIC (Fuji II-FII), nano-filled resin-modified GIC (Ketac™ N100-N100) and an etch-and-rinse adhesive system with a composite resin (Adper™ Single Bond 2 and Z100™-Z100). All tests were performed with a Universal Testing Machine (24 h water storage, crosshead speed of 1 mm/min). Debonded surfaces were examined with a stereomicroscope (×40) to identify the failure mode. The data was analyzed with two-way ANOVA (p < 0.05) and LSD test.

RESULTS

Means were statistically different regarding the tests and materials, indicating that values for BS obtained for each material depend on the test performed. Failure analysis revealed that failures produced by μTBS were mainly cohesive for KM and FII. μSBS failures were mainly adhesive or mixed for all materials. For the μTBS, the rank was Z100 > FII > KM = N100, whereas for the μSBS it was Z100 = FII = KM > N100.

CONCLUSION

It may be concluded that distinct micro-mechanical tests present different failure patterns and rankings depending on the material to be considered.

Survival rate of approximal-ART restorations using a two-layer technique for glass ionomer insertion

OBJECTIVE

Good survival rates (SR) have been reported for occlusal-atraumatic restorative treatment (ART) restorations but not for approximal-ART restorations. The high-viscosity consistency of the glass ionomer cement (GIC) may lead to its incorrect adaptation into the cavity and thus to failure of the restoration. Because the use of a flowable GIC layer seemed to improve its adaptation in approximal restorations in vitro, we evaluated whether the use of an intermediate flowable GIC layer would improve the SR of approximal-ART restorations.

METHODS

A total of 208 children (6-7 years old) with at least one occluso-proximal carious lesion in a primary molar were selected and randomly allocated to two groups: G1, conventional technique, one-layer GIC (powder/liquid ratio 1:1); and G2, two-layer technique, consisting of a first layer of GIC with a flowable consistency (powder/liquid ratio 1:2) and a second layer of a regular consistency. Restorations were made by final-year students and evaluated after 1, 6, 12 and 18 months. Restoration survival was evaluated using Kaplan-Meier survival and logrank test. Poisson regression analyses (α = 5) were used to verify the influence of factors such as insertion technique, restoration surface and operators.

RESULTS

The overall SR of the restorations after 18 months was 68 %. There was no difference in SR between the techniques, neither did the other factors influence the SR.

CONCLUSIONS

Over 18 months, the use of an intermediate flowable GIC layer in approximal-ART restorations does not improve the restoration survival.

CLINICAL RELEVANCE

This study suggests that the two-layer technique is not the answer for increasing approximal-ART restoration longevity.

Effect of antibacterial agents on the surface hardness of a conventional glass-ionomer cement

In atraumatic restorative treatment (ART), caries removal with hand excavation instruments is not as efficient as that with rotary burs in eliminating bacteria under the glass ionomer cements (GICs). Thus, different antibacterial agents have been used in recent studies to enhance the antibacterial properties of the GICs, without jeopardizing their basic physical properties.

OBJECTIVE

The objective of this study was to evaluate the effect of antibacterial agents on the surface hardness of a conventional GIC (Fuji IX) using Vickers microhardness [Vickers hardness number (VHN)] test.

MATERIAL AND METHODS

Cetrimide (CT), cetylpyridinium chloride (CPC) and chlorhexidine (CHX) were added to the powder and benzalkonium chloride (BC) was added to the liquid of Fuji IX in concentrations of 1% and 2%, and served as the experimental groups. A control group containing no additive was also prepared. After the completion of setting reaction, VHN measurements were recorded at 1, 7, 15, 30, 60, and 90 days after storage in 37°C distilled water. A one-way ANOVA was performed followed by a Dunnett t test and Tamhane T2 tests and also repeated measurements ANOVA was used for multiple comparisons in 95% confidence interval.

RESULTS

VHN results showed significant differences between the control and the experimental groups at all time periods (p<0.05 for all). Significant differences were observed between all study periods for individual groups (p<0.05). After 7 days, VHNs were decreased in all experimental groups while they continued to increase in the control group. BC and CHX groups demonstrated the least whereas CT and CPC groups exhibited most adverse effect on the hardness of set cements.

CONCLUSIONS

Despite the decreased microhardness values in all experimental groups compared to the controls after 7 up to 90 days, incorporating certain antibacterial agents into Fuji IX GIC showed tolerable microhardness alterations within the limitations of this in vitro study.

Twenty-five-year atraumatic restorative treatment (ART) approach: a comprehensive overview

Background

The atraumatic restorative treatment (ART) approach was born 25 years ago in Tanzania. It has evolved into an essential caries management concept for improving quality and access to oral care globally.

Results

Meta-analyses and systematic reviews have indicated that the high effectiveness of ART sealants using high-viscosity glass ionomers in carious lesion development prevention is not different from that of resin fissure sealants. ART using high-viscosity glass ionomer can safely be used to restore single-surface cavities both in primary and in permanent posterior teeth, but its quality in restoring multiple surfaces in primary posterior teeth cavities needs to be improved. Insufficient information is available regarding the quality of ART restorations in multiple surfaces in permanent anterior and posterior teeth. There appears to be no difference in the survival of single-surface high-viscosity glass-ionomer ART restorations and amalgam restorations.

Discussion

The use of ART results in smaller cavities and in high acceptance of preventive and restorative care by children. Because local anaesthesia is seldom needed and only hand instruments are used, ART is considered to be a promising approach for treating children suffering from early childhood caries. ART has been implemented in the public oral health services of a number of countries, and clearly, proper implementation requires the availability of sufficient stocks of good high-viscosity glass ionomers and sets of ART instruments right from the start. Textbooks including chapters on ART are available, and the concept is being included in graduate courses at dental schools in a number of countries. Recent development and testing of e-learning modules for distance learning has increasingly facilitated the distribution of ART information amongst professionals, thus enabling more people to benefit from ART. However, this development and further research require adequate funding, which is not always easily obtainable. The next major challenge is the continuation of care to the frail elderly, in which ART may play a part.

Conclusion

ART, as part of the Basic Package of Oral Care, is an important cornerstone for the development of global oral health and alleviating inequality in oral care.

Poor quality evidence suggests that failure rates for atraumatic restorative treatment and conventional amalgam are similar

DATA SOURCES

The Medline, Cochrane CENTRAL, Biomed Central, Database of Open Access Journals (DOAJ), OpenJ-Gate, Bibliografia Brasileira de Odontologia (BBO), LILACS, IndMed, Sabinet, Scielo, Scirus (Medicine), OpenSIGLE and Google Scholar databases were searched. Hand searching was performed for journals not indexed in the databases. References of included trials were checked.

STUDY SELECTION

Prospective clinical trials with test and control groups with a follow up of at least one year were included.

DATA EXTRACTION AND SYNTHESIS

Data abstraction was conducted independently and clinical and methodologically homogeneous data were pooled using a fixed-effects model.

RESULTS

Eighteen trials were included. From these 32 individual dichotomous datasets were extracted and analysed. The majority of the results show no differences between both types of intervention. A high risk of selection-, performance-, detection- and attrition bias was identified. Existing research gaps are mainly due to lack of trials and small sample size.

CONCLUSIONS

The current evidence indicates that the failure rate of high-viscosity GIC/ART restorations is not higher than, but similar to that of conventional amalgam fillings after periods longer than one year. These results are in line with the conclusions drawn during the original systematic review. There is a high risk that these results are affected by bias, and thus confirmation by further trials with suitably high numbers of participants is needed.

Paediatric dentistry education of atraumatic restorative treatment (ART) in Brazilian dental schools

AIM

To evaluate the degree of knowledge, use and teaching of atraumatic restorative treatment (ART) of paediatric dentistry lecturers in dental schools throughout Brazil.

METHODS

A structured questionnaire was applied, containing questions regarding the use of ART, socio-demographic characteristics and academic degree background. Descriptive analysis and Poisson's regression were conducted in order to verify the association between exploratory variables and ART teaching (α=5%).

RESULTS

Of the 721 questionnaires sent to dental schools, approximately 40% were returned (n=285). Some 98.2% of the participants teach ART.

STATISTICS

Concerning dental lecturers who teach ART, in multiple regression model, considering ART indication (emergency versus restorative treatment) the lecturers residents of the Mid-West (PR=1.66; CI:1.13-2.45) and Northeast region (PR=1.33; CI:1.02-1.72) and lecturers who use ART regularly (PR=3.73; CI:2.11-5.59) teach ART as restorative treatment. When the question was about reason for using ART (conservative technique versus other techniques failures/fast treatment), lecturers with a longer period of TG (time elapsed since graduation) (PR=1.30; CI:1.08- 1.56) and also lecturers who use ART regularly (PR=2.87; CI:1.95-4.22), teach it as being a conservative technique. Regarding the patients' age covered by ART (versus without limitation), women (PR=1.26; CI:1.06-1.50) and lecturers who use ART regularly (PR=1.28; CI:1.06-1.54), teach that there is no age restriction.

CONCLUSIONS

ART has been widely taught in Brazilian dental schools, is regularly used in lecturer's clinical practices and has positively influenced the appropriate teaching of this technique.

Microhardness and chemical analysis of high-viscous glass-ionomer cement after 10 years of clinical service as ART restorations

OBJECTIVES

The aim of this study was to evaluate the Knoop microhardness (KHN) and chemical composition of high-viscous glass-ionomer cement (HVGIC) after 10 years of clinical service.

METHODS

Six HVGIC samples were cut from 10-year ART restorations. The sections were embedded in acrylic moulds with their longitudinal profile exposed. KHN was determined by performing three sequences of five indentations at 10, 30, 50, 70 and 90 μm of HVGIC outer surface. For the control group (n=6), HVGIC specimens were stored in distilled water for 24 months. Hardness measurements were taken at days 7, 30, 60, 120, 180, 360, and 720. For chemical analysis using SEM-EDX, 10-year and control specimens were dehydrated and coated with carbon. Data were analysed using T-test and ANOVA/Tukey's test (p<0.05).

RESULTS

A significant KHN increase was observed in the control group up to the 180-day period. From this point the values stabilized and no more significant differences were found between the 10-year and the control KHN values. No statistical differences were observed amongst the KHN from inner distances compared to the outer surface of the 10-year HVGIC specimens. In one 10-year specimen, SEM-images identified the transformation of HVGIC in an altered layer with no glass filler particles detectable, and raised Ca, K and P contents.

CONCLUSIONS

KHN values of ten-year HVGIC specimens were similar to the control group values at 180-day storage period. Except for one 10-year specimen in that an altered layer could be seen, chemical composition was similar amongst the depths evaluated.

Antibacterial activity and physical properties of conventional glass-ionomer cements containing chlorhexidine diacetate/cetrimide mixtures

STATEMENT OF THE PROBLEM

Hand excavation instruments are not as efficient as that with rotary burs in atraumatic restorative treatment (ART).

PURPOSE

To evaluate the antibacterial activity (ABA), microhardness numbers (VHN), and cumulative fluoride releasing (CFR) patterns of conventional GICs (Fuji IX (FX) and Ketac Molar (KM)) containing chlorhexidine diacetate/cetrimide mixtures (2.5%/2.5%) (AB).

MATERIALS AND METHODS

The powders of ABs were added to powders of FX and KM selected as experimental groups (EXPs). FX and KM were assigned as controls (CNTs). ABA against S.mutans (MS) and L.casei (LB) were examined between 1-90 days. VHN were calculated after 24 hours and CFR patterns measured between 1-30 days. Analysis of variance was used for comparison (p<0.05)

RESULTS

Differences were found between EXPs regarding MS levels at days 1, 7 and 60 as well as for LB at all time periods (p<0.05). VHN decreased in EXPs compared to CNTs (p<0.05), and no differences were found between EXPs (p>0.05). CFR patterns tended to decrease in EXPs compared to the CNTs, but no differences were found between EXPs (p>0.05) CLINICAL SIGNIFICANCE These mixtures could be recommended for ART procedures to provide beneficial antibacterial effects without seriously deteriorating the physical properties of selected GICs.

Evolution of the the ART approach: highlights and achievements

Atraumatic Restorative Treatment (ART) was initiated in the mid-eighties in Tanzania in response to an inappropriately functioning community oral health programme that was based on western health care models and western technology. The approach has evolved to its present standing as an effective minimal intervention approach mainly because the originators anticipated the great potential of ART to alleviate inequality in oral health care, and because they recognised the need to carry out research to investigate its effectiveness and applicability. Twenty-five years later, ART was accepted by the World Health Organisation (1994) and the FDI World Dental Federation (2002). It is included in textbooks on cariology, restorative dentistry and minimal intervention dentistry. It is being systematically introduced into public oral health service systems in a number of low- and middle income countries. Private practitioners use it. Many publications related to aspects of ART have been published and many more will follow. To achieve quality results with ART one has to attend well-conducted and sufficiently long training courses, preferably in combination with other caries preventive strategies. ART should, therefore, not be considered in isolation and must be part of an evidence-based approach to oral health with a strong foundation based on prevention.

Transferring ART research into education in Brazil

The aim of this study was to evaluate the teaching of the Atraumatic Restorative Treatment (ART) approach in Brazilian dental schools.

MATERIALS AND METHODS

A questionnaire on this subject was sent to Pediatric Dentistry, Operative Dentistry and Public Health Dentistry professors. The questions approached the following subjects: the method used to teach ART, the time spent on its teaching, under which discipline it is taught, for how many years ART has been taught and its effect on the DMFT index.

RESULTS

A total of 70 out of 202 dental schools returned the questionnaire. The ART approach is taught in the majority of the Brazilian dental schools (96.3%), and in most of these schools it is taught both in theory and in clinical practice (62.9%). The majority (35.3%) of professors teach ART for 8 hours, and most often as part of the Pediatric Dentistry discipline (67.6%). It has been taught for the last 7 to 10 years in 34.3% of dental schools. Most professors did not observe a change in the DMFT index with this approach. There is a diversity in the teaching of ART in Brazil in terms of the number of hours spent, the teaching method (theory and practice), and the disciplines involved in its teaching.

CONCLUSIONS

It is necessary to address the training of professors in the ART approach for the whole country. An educational model is proposed whereby a standard ART module features as part of other preventive and restorative caries care educational modules. This will facilitate and standardize the introduction and adoption of the ART approach in undergraduate education in Brazil.

[Evaluation of the perception of the oral health teams of the municipal health department of Curitiba, Paraná State, regarding atraumatic restorative treatment (ART)]

An evaluation was made of the perception of oral health teams regarding Atraumatic Restorative Treatment (ART) as a primary oral healthcare strategy used by the Municipal Health Department of Curitiba, Paraná State. A study was made both of Health Units (HU) that operate using the Family Health Strategy (FHSHU) and those that do not (Basic Healthcare Units--BHU). The sample involved 191 oral health professionals proportionally (CI=95%, e=6%). A questionnaire was used to collect data. The information was analyzed using the SPSS 13.0 program. The response rate was 82%. Chi-square testing did not reveal a statistically significant difference between the FHSHU (83.1%) and the BHU (74.3%) with regard to knowledge about the technique (p>0.05). A difference was found as to training in ART among the different HU (p<0.01) and the use of the technique by the services (p<0.01). The length of training and the length of service of dental health professionals at the municipal health service were relevant in relation to knowledge of the technique and the taking of clinical decisions as to ART. The conclusion was reached that training on ART is needed at the primary healthcare level as a result of the different perceptions revealed.

El tratamiento restaurador atraumático (TRA) como parte de un paquete básico de servicios de salud oral en el área rural de Bolivia

El objetivo fue preservar la salud oral de escolares con alta prevalencia de caries, mediante la aplicación del tratamiento restaurador atraumático (TRA) y la realización de acciones de promoción en el área rural de Bolivia. La intervención, realizada en 2006 y 2007, se basó en resultados de estudios que demuestran la efectividad de la técnica en diferentes contextos y periodos de tiempo. Su aplicación fue masiva en unidades escolares y se acompañó sólidamente con acciones de promoción. Los resultados mostraron una cobertura del 95% del grupo objetivo y un 75,4% de supervivencia de las restauraciones a los 24 meses.

Two years survival rate of Class II ART restorations in primary molars using two ways to avoid saliva contamination

AIM

To compare the survival rates of Class II Atraumatic Restorative Treatment (ART) restorations placed in primary molars using cotton rolls or rubber dam as isolation methods.

METHODS

A total of 232 children, 6-7 years old, both genders, were selected having one primary molar with proximal dentine lesion. The children were randomly assigned into two groups: control group with Class II ART restoration made using cotton rolls and experimental group using rubber dam. The restorations were evaluated by eight calibrated evaluators (Kappa > 0.8) after 6, 12, 18 and 24 months.

RESULTS

A total of 48 (20.7%) children were considered dropout, after 24 months. The cumulative survival rate after 6, 12, 18 and 24 months was 61.4%, 39.0%, 29.1% and 18.0%, respectively for the control group, and 64.1%, 55.1%, 40.1% and 32.1%, respectively for the rubber dam group. The log rank test for censored data showed no statistical significant difference between the groups (P = 0.07). The univariate Cox Regression showed no statistical significant difference after adjusting for independent variables (P > 0.05).

CONCLUSION

Both groups had similar survival rates, and after 2 years, the use of rubber dam does not increase the success of Class II ART restorations significantly.

Class III atraumatic restorative treatment (ART) in adults living in West Africa--outcomes after 48 months

OBJECTIVES

This observational study assessed the effectiveness of class III restorations using the atraumatic restorative treatment (ART) approach in permanent anterior teeth over a 48-month period.

METHODS

Dental auxiliaries placed a total of 117 class III ART restorations in 2004, using a cosmetically improved glass-ionomer (Ionofil® Plus; VOCO, Cuxhafen, Germany), in 67 patients with a mean age of 27.3 years in the rural Jahali Health Center, The Gambia. Independent examiners evaluated the restorations after 24 and 48 months using the clinical ART evaluation criteria.

RESULTS

Seventy-six of the restorations could be observed over 48 months in 51 patients. After 48 months, 53 of 76 restorations were classified as clinically acceptable (without or with minor intervention (repair) needed), and 23 restorations were classified as insufficient. There was no statistical difference in a clustered performance rating between restorations placed in central and lateral incisors (P=1.0).

CONCLUSIONS

The adoption of the ART approach to class III caries cavities made restorative dental care in anterior teeth available in a West African region. The long-term performance was comparable to other studies. Longitudinal clinical studies with greater populations are required to substantiate these results.

Changes in the quality of life of Tanzanian school children after treatment interventions using the Child-OIDP

This study aimed to examine the evaluative properties of the Child Oral Impacts on Daily Performances (Child-OIDP) inventory and to estimate treatment-associated changes in the OIDP and self-reported oral health following atraumatic restorative treatment (ART) and oral health education (OHE). A total of 1,306 school attendees in Kilwa, Tanzania, completed the Child-OIDP inventory before, and 6 months after, treatment. The post-treatment questionnaire assessed change in perceived oral health. Complete baseline and follow-up data were obtained for 104, 117, and 1,085 participants who received, respectively, ART fillings (Group A), ART fillings and tooth extraction (Group B), and OHE only (Group C). The longitudinal validity, responsiveness, and treatment-associated changes were calculated using anova, effect sizes, and repeated general linear models (GLM). The follow-up prevalence was 73.8%. The mean changes in the OIDP total- and subscale scores were negative within those who reported 'worsened' oral health, and positive in subjects reporting 'improved' oral health. Effect sizes for the total OIDP score ranged from -0.2 within the category 'worsened' to 0.4 within the category 'improved'. Changes following treatment were more extensive in Group B compared with Groups A and C, and in Group C compared with Group A. The Child-OIDP showed promising evaluative properties and responsiveness to change following ART fillings, ART fillings and tooth extraction, and OHE.

Influence of the experience of operator and assistant on the survival rate of proximal ART restorations: two-year results

AIM

The objective of the study was to determine the influence of the experience of the operator and the assistant on the survival rate of proximal ART- restorations after 2 years when placed using two methods of tooth-isolation and three glass ionomer cement-brands.

STUDY DESIGN

A clinical intervention study.

METHODS

Each of 804 children aged 6-8 years received one proximal restoration in their primary molars. The restorations were placed by 'experienced/inexperienced' operators randomly paired with 'experienced/ inexperienced' assistants. The atraumatic restorative treatment (ART) approach was used with 3 brands of glass ionomer cements (GIC) and 2 tooth-isolation methods (rubber dam vs cotton rolls). Trained and calibrated evaluators evaluated the restorations, soon after placement and after 2 years.

STATISTICS

The data collected were analyzed using SPSS 14.0, to determine and relate the survival rate of the restorations to the operator and assistant with respect to the other factors such as the restorative material used and the isolation method applied.

RESULTS

After 2 years, the survival rate of the restorations was 30.8%. In general, there were no statistical significant differences in the survival rate of the restorations made by the 'experienced' vs 'inexperienced' operators, but individually, the operator with more experience was associated with a significantly higher survival rate of the restorations. The experienced assistants were associated with significantly higher survival rates of the restorations. The most 'experienced' operator paired with any 'experienced' assistant and using rubber dam tooth-isolation method, was associated with a significantly higher survival rate of the restorations.

CONCLUSION

The combination of the 'experienced' operator and assistant using rubber dam tooth-isolation method had the best chance of survival for proximal ART restorations, irrespective of the material-brand used.

Ten-year survival of ART restorations in permanent posterior teeth

This study evaluated the 10-year clinical performance of high-viscosity glass-ionomer cement placed in posterior permanent teeth by means of the Atraumatic Restorative Treatment (ART) approach. One operator placed 167 single- and 107 multiple-surface restorations in 43 high-risk caries pregnant women (mean decayed teeth = 9.8 ± 5.5). Examinations were performed at 1-, 2-, and 10-year intervals according to ART criteria. In the last evaluation, the US Public Health Service (USPHS) criteria were also used. After 10 years, 129 restorations (47.1%) were evaluated and achieved a cumulative survival rate of 49.0% (SE 7.2%). The 10-year survival of single- and multiple-surface ART restorations assessed using the ART criteria were 65.2% (SE 7.3%) and 30.6% (SE 9.9%), respectively. This difference was significant (jackknife SE of difference; p < 0.05). Using the USPHS criteria, the 10-year survival of single- and multiple-surface ART restorations were 86.5% and 57.6%, respectively. The primary causes of failure were total loss (9.3%) and marginal defects (5.4%). The survival rates observed, especially for the single-surface restorations, confirm the potential of the ART approach for restoring and saving posterior permanent teeth.

Strong nanocomposites with Ca, PO(4), and F release for caries inhibition

This article reviews recent studies on: (1) the synthesis of novel calcium phosphate and calcium fluoride nanoparticles and their incorporation into dental resins to develop nanocomposites; (2) the effects of key microstructural parameters on Ca, PO(4), and F ion release from nanocomposites, including the effects of nanofiller volume fraction, particle size, and silanization; and (3) mechanical properties of nanocomposites, including water-aging effects, flexural strength, fracture toughness, and three-body wear. This article demonstrates that a major advantage of using the new nanoparticles is that high levels of Ca, PO(4), and F release can be achieved at low filler levels in the resin, because of the high surface areas of the nanoparticles. This leaves room in the resin for substantial reinforcement fillers. The combination of releasing nanofillers with stable and strong reinforcing fillers is promising to yield a nanocomposite with both stress-bearing and caries-inhibiting capabilities, a combination not yet available in current materials.

Research proposal: evaluation of ART in adult patients

The primary objective of the Atraumatic Restorative Treatment (ART) is to reduce the indication of tooth extraction by means of a low-cost technique. Considering the difficulties of Brazilian public services to meet the demand of care of the low-income population, with lack of care to the adult population, which usually receives only emergency care, the aim of this study is to assess the performance of high-viscosity glass ionomer cements accomplished by the modified atraumatic restorative treatment in one- and multiple-surface cavities, compared to the conventional restorative approach. It will be analyzed the clinical performance of the materials; cost (material and human resources); patient satisfaction with the treatment received; and preventive effect of treatment.

Clinical evaluation of glass-ionomer cement restorations

This article mentions the general structure, properties and clinical performance of conventional and resin-modified glass-ionomer cements, focusing on adhesion, caries inhibition effect and recommendations of their use.

Physical-mechanical properties of glass ionomer cements indicated for atraumatic restorative treatment

BACKGROUND

This study evaluated mechanical properties of glass ionomer cements (GICs) used for atraumatic restorative treatment. Wear resistance, Knoop hardness (Kh), flexural (F(s)) and compressive strength (C(s)) were evaluated. The GICs used were Riva Self Cure (RVA), Fuji IX (FIX), Hi Dense (HD), Vitro Molar (VM), Maxxion R (MXR) and Ketac Molar Easymix (KME).

METHODS

Wear was evaluated after 1, 4, 63 and 365 days. Two-way ANOVA and Tukey post hoc tests (P = 0.05) analysed differences in wear of the GICs and the time effect. F(s), C(s), and Kh were analysed with one-way ANOVA.

RESULTS

The type of cement (p < 0.001) and the time (p < 0.001) had a significant effect on wear. In early-term wear and Kh, KME and FIX presented the best performance. In long-term wear, F(s) and C(s), KME, FIX and HD had the best performance. Strong explanatory power between F(s) and the Kh (r(2) = 0.85), C(s) and the Kh (r(2) = 0.82), long-term wear and F(s) of 24 h (r(2) = 0.79) were observed.

CONCLUSIONS

The data suggested that KME and FIX presented the best in vitro performance. HD showed good results except for early-term wear.

Child-Centred child management in a changing world

BACKGROUND

There is a need to "re-think" child management, as the completion of a procedure is not the only dental goal. Short versus long-term goals and the behavioural and pharmacologic repertoire will influence outcomes.

REVIEW

A child-centred approach is described, with a specific protocol for the dental waiting room. The changing attitudes of society need to be taken into account in the use of behaviour management techniques by paediatric dentists.

CONCLUSION

The goal of managing children in the dental environment requires some thought: the welfare of the child depends on attention by a clinician to long term goals. The contemporary child-centred clinician has a wide range of child management skills. It is not optional for the clinician to develop his/her behavioural expertise to a high level; clinician skills have long-term consequences. These days behaviour management begins in the waiting room where initial contact provides the opportunity to shape subsequent behaviours.

Six-year follow up of atraumatic restorative treatment restorations placed in Chinese school children

OBJECTIVES

This study aimed to evaluate the clinical performance of atraumatic restorative treatment (ART) restorations placed in school children in China over a 6-year period.

METHODS

This study was implemented in 1996 and 294 ART restorations were placed in 197 children aged 12-13 years by five assistant dentists in four schools. Standard ART procedures and instruments were used combined with a high-strength glass-ionomer restorative material. One examiner evaluated the restorations annually using the ART criteria while at 5 years an independent external examiner used US Public Health Service (USPHS) criteria.

RESULTS

Fifty-eight per cent of the restorations were followed for 6 years. At the 6-year evaluation examination, 76% and 59% of the small and large restorations respectively were present and were without major wear or defect (P < 0.01). Similar results were obtained when using the USPHS criteria. Results of a multilevel survival analysis show that the correlation between restoration failure and operator was small but failure of restorations placed in the same child was substantial. Net wear of the small and large restorations after 6 years were 176 and 172 microm respectively (P > 0.05).

CONCLUSION

The 6-year survival rate of the class I ART restorations in this study, especially the smaller ones, was satisfactory. This suggests that the ART approach can be used in the school setting to improve the oral health of large populations of underserved children.

Three-year survival of single- and two-surface ART restorations in a high-caries child population

The aim of this study was to evaluate the survival of single- and two-surface atraumatic restorative treatment (ART) restorations in the primary and permanent dentitions of children from a high-caries population, in a field setting. The study was conducted in the rainforest of Suriname, South America. ART restorations, made by four Dutch dentists, were evaluated after 6 months, 1, 2, and 3 years. Four hundred seventy-five ART restorations were placed in the primary dentition and 54 in first permanent molars of 194 children (mean age 6.09 ± 0.48 years). Three-year cumulative survivals of single- and two-surface ART restorations in the primary dentition were 43.4 and 12.2%, respectively. Main failure characteristics were gross marginal defects and total or partial losses. Three-year cumulative survival for single-surface ART restorations in the permanent dentition was 29.6%. Main failure characteristics were secondary caries and gross marginal defects. An operator effect was found only for two-surface restorations. The results show extremely low survival rates for single- and two-surface ART restorations in the primary and permanent dentitions. The variable success for ART may initiate further discussion about alternative treatment strategies, especially in those situations where choices have to be made with respect to a well-balanced, cost-effective package of basic oral health care.

Influence of local anaesthesia on the quality of class II glass ionomer restorations

OBJECTIVE

To investigate the influence of local anaesthesia on the quality of class II glass ionomer restorations with discomfort as cofactor.

MATERIAL AND METHODS

The study population consisted of 6- to 7-year-old schoolchildren in Paramaribo and its environs. To be included, each child needed to have a proximally situated cavity in a primary molar that was accessible to hand instruments and where no pulp exposure was expected. They were randomly divided into four treatment groups: conventional method with and without local anaesthesia and atraumatic restorative treatment method (ART) with and without local anaesthesia. The restoration quality was scored using the evaluation criteria for ART restorations (successful if restoration is correct or has a minor defect and fails if defects are larger than 0.5 mm, if secondary caries is observed, if the restoration is fractured, partly or totally lost or if the pulp is involved) at 6 and 30 months after treatment. The extent of discomfort was registered by assessing the behaviour (modified Venham score) and observing the heart rate during treatment.

RESULTS

For this study 153 children were treated with hand instruments (ART) and 146 children with rotary instruments (conventional method). A total of 198 restorations were evaluated during follow-up periods. There were no significant differences in patient discomfort between the ART and the conventional group and between the anaesthesia and the non-anaesthesia group. The conventional restorations demonstrated significantly higher success rates than ART restorations after 6 (P = 0.001) and 30 months (P = 0.032). There were no significant differences in success rate between the anaesthesia and the non-anaesthesia group.

CONCLUSION

Local anaesthesia has no influence on discomfort during treatment. Furthermore, discomfort during treatment does not affect the success rate of restorations.

Effects of incorporating nanosized calcium phosphate particles on properties of whisker-reinforced dental composites

Clinical data indicate that secondary caries and restoration fracture are the most common problems facing tooth restorations. Our ultimate goal was to develop mechanically-strong and caries-inhibiting dental composites. The specific goal of this pilot study was to understand the relationships between composite properties and the ratio of reinforcement filler/releasing filler. Nanoparticles of monocalcium phosphate monohydrate (MCPM) were synthesized and incorporated into a dental resin for the first time. Silicon carbide whiskers were fused with silica nanoparticles and mixed with the MCPM particles at MCPM/whisker mass ratios of 1:0, 2:1, 1:1, 1:2, and 0:1. The composites were immersed for 1-56 days to measure Ca and PO4 release. When the MCPM/whisker ratio was changed from 0:1 to 1:2, the composite flexural strength (mean +/- SD; n = 5) decreased from 174 +/- 26 MPa to 138 +/- 9 MPa (p < 0.05). A commercial nonreleasing composite had a strength of 112 +/- 14 MPa. When the MCPM/whisker ratio was changed from 1:2 to 1:1, the Ca concentration at 56 days increased from 0.77 +/- 0.04 mmol/L to 1.74 +/- 0.06 mmol/L (p < 0.05). The corresponding PO4 concentration increased from 3.88 +/- 0.21 mmol/L to 9.95 +/- 0.69 mmol/L (p < 0.05). Relationships were established between the amount of release and the MCPM volume fraction v(MCPM) in the resin: [Ca]= 42.9 v(MCPM) (2.7), and [PO4] = 48.7 v(MCPM) (1.4). In summary, the method of combining nanosized releasing fillers with reinforcing fillers yielded Ca- and PO4-releasing composites with mechanical properties matching or exceeding a commercial stress-bearing, nonreleasing composite. This method may be applicable to the use of other Ca-PO4 fillers in developing composites with high stress-bearing and caries-preventing capabilities, a combination not yet available in any dental materials.

Factors inhibiting the implementation of the Atraumatic Restorative Treatment approach in public oral health services in Gauteng Province, South Africa

OBJECTIVE

To investigate potential barriers to the utilisation of the ART approach in a South African public oral health service.

METHOD

7 barriers were identified: patient load/work load, operator opinion, patient opinion, service management, material supply, clinical ART skill, chair-side assistance. Operators were asked to answer a questionnaire one year after completing the ART training. Responses ranged from 1 = no barrier to 5 = highest barrier. Treatment data per operator were collected during 1 year after training, for both dentitions, including: number of extracted teeth, placed traditional restorations, ART restorations. The restoration/extraction (REX) ratio and the proportion of ART restorations (ART%) of the total number of restorations were calculated and correlated with the barrier variables. Pearson correlation, ANOVA and 2-tailed t-tests were used in the statistical analyses.

RESULTS

Patient load/work load (mean = 2.80: SE = 0.16) was the strongest barrier (p<0.001) and clinical ART skill was the weakest barrier (p<0.001). A significant correlation between material supply and mean REX score was observed in both dentitions. In primary teeth, the ART% correlated significantly with clinical ART skill (r= -0.63; p<0.01). In permanent teeth, statistically significant correlations were observed between ART% and patient load/work load (r = -0.54; p<0.05), patient opinion (r = -0.76; p<0.01), operator opinion (r = -0.53; p<0.05), chair-side assistance (r = -0.57; p<0.05), oral health service management (r = -0.46; p<0.05).

CONCLUSIONS

1 year after ART training completion high patient load/work load, followed by insufficient provision of materials/instruments, were the two most inhibiting barriers to the use of ART in the public oral health services. Dentists' perceptions of low clinical skill levels in performing ART confidently inhibited the use of ART in primary teeth in children.

ART and conventional root restorations in elders after 12 months

Successful use of atraumatic restorative treatment (ART) in children has been reported, but little information is available regarding its use in older adults. The hypothesis of this study was that survival rates of root restorations placed by both ART and the conventional technique were similar. Root-surface caries lesions in 103 institutionalized elders in Hong Kong were treated randomly by either: (1) the conventional approach-caries removed by dental burs, and the cavity filled with light-cured resin-modified glass ionomer; or (2) the ART approach-caries removed by hand instruments, and the cavity filled with chemically cured high-strength glass ionomer. In total, 84 conventional and 78 ART restorations were placed. After 12 months, 63 conventional and 59 ART restorations were reviewed, and the respective 12-month survival rates were 91.7% and 87.0% (p > 0.05). It is concluded that the survival rates of both types of root restorations were high and similar.

Antibacterial effects and physical properties of glass-ionomer cements containing chlorhexidine for the ART approach

OBJECTIVES

Since atraumatic restorative treatment (ART) involves removal of carious lesions with manual instruments, improvement of filling materials to guarantee greater success should be considered. This study aimed to evaluate antibacterial, physical, and bonding properties of glass-ionomer cements (GIC) containing chlorhexidine (CHX), and to determine optimal concentrations for incorporation of agents to obtain antibacterial GICs for use with the ART approach.

METHODS

CHX diacetate combined with CHX dihydrochloride was added to control GIC powder to obtain concentration ratios of 1/0, 2/0, 3/0, 1/1, or 2/2% w/w. Antibacterial activity of each cement against Streptococcus mutans, Lactobacillus casei or Actinomyces naeslundii was examined using agar-diffusion methods, and release of CHX was analyzed by HPLC. Compressive strength, bond strength to dentin, and setting time were measured, and compared with those of control samples.

RESULTS

All experimental GICs exhibited inhibition of three bacteria, but sizes of inhibition zones and concentrations of CHX released were not dependent upon CHX content. Incorporation of CHX diacetate at 2% or greater, significantly decreased compressive strength, and bond strength to dentin was adversely affected by addition of CHX diacetate at 2% or more (p<0.05, ANOVA, Fisher's PLSD test), although setting time was extended a little by addition of any concentrations of CHX.

SIGNIFICANCE

The present results demonstrate that experimental GICs containing CHX are effective in inhibiting bacteria associated with caries, and incorporation of 1% CHX diacetate is optimal to give appropriate physical and bonding properties.