Atraumatic restorative treatment

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Atraumatic restorative treatment (ART) [1] is a method for cleaning out tooth decay (dental caries) from teeth using only hand instruments (dental hatchet and spoon-excavator) and placing a filling. It does not use rotary dental instruments (dental drills) to prepare the tooth and can be performed in settings with no access to dental equipment. No drilling or local anaesthetic injections are required. ART is considered a conservative approach, not only because it removes the decayed tissue with hand instruments, avoiding removing more tissue than necessary which preserves as much tooth structure as possible, but also because it avoids pulp irritation and minimises patient discomfort. ART can be used for small, medium and deep cavities (where decay has not reached the tooth nerve dental pulp) [1] caused by dental caries.

Contents

In shallow to medium-sized cavities (lesions), the decayed tissue removal is carried out until the soft tissue (demineralised dentine) is completely removed and harder tissue is reached (firm dentine). In deeper cavities (lesions that reach more than two-thirds of dentine thickness on a radiograph), the removal of the decay must be carried out more carefully in order to avoid reaching the tooth's pulp (dental nerve). Soft tissue should be left on the cavity floor. The decision on how much decay to remove (whether to carry out the decay removal to firm dentine or stop when soft dentine has been reached) depends on the depth of the cavity (a filling needs to have a minimum thickness of material to remain strong); [2] and the possibility of reaching the tooth's pulp (the nerve is exposed sometimes when deep cavities are accessed with rotary burs or vigorously with hand instruments, compromising the tooth's vitality).

Dental radiographs need to be taken to evaluate the depth of the cavity and extension of decay. If too deep and close to the pulp, only the soft decayed tissue is removed from the cavity floor to avoid the risk of pulp exposure.

ART is suitable for both primary (baby teeth) and permanent dentition (adult teeth) and has a large evidence base[ specify ] supporting it.

Background and history

ART was firstly introduced by the dentist Jo Frencken in 1985. [3] It was introduced in Tanzania, where access to dental treatments using drills was restricted by limited dentist availability and a lack of electricity and or piped water. As a result, children's teeth generally decayed until they caused pain or infection and removal was required. At that time, the dentists tried to use only hand instruments to open and/or enlarge small cavities and selectively remove the decayed tissue, followed by the placement of a glass ionomer cement, an adhesive filling that also releases fluoride and helps the tooth's "recovery" from decay (remineralisation). This treatment was tested in clinical trials and found to be effective.[ citation needed ]

Although ART was initially developed in response to the needs of populations with less access to dental care, it had similar outcomes to more invasive treatments (local anaesthetic and drilling the tooth with dental bur). This means that it is suitable for use in any type of setting (from deprived communities to dental clinics) and it has been widely adopted into mainstream care. Due to its "atraumatic approach", it has also been proven to be beneficial for patients with dental anxiety or learning disabilities, even where there is adequate dental care, as neither drilling nor local anaesthetics are required.[ citation needed ]

During the International Caries Consensus Collaboration (ICCC) meeting held in Leuven in 2015, ART was recommended by an international group of experts in cariology, restorative and paediatric dentistry as an option to treat decayed primary and permanent teeth with decay where restorative options were indicated, such as cavities that were difficult to clean using only toothbrushes and fluoride toothpaste. [4] [2]

Concept

There are two different ART procedures with different aims: preventive (ART fissure sealant for non-cavitated teeth); and restorative (ART filling for decayed and cavitated teeth) [3] [5] [6] [7]

Preventive

Adult teeth that erupt behind the baby back teeth have deep grooves (fissures) and are more susceptible to accumulating food debris and dental plaque which can stagnate and lead to decay. They are also difficult to toothbrush properly. While they are erupting, they are very susceptible to decay and it is very difficult to keep them dry enough to use a resin-based sealant material successfully. However, sealing the tooth pits and fissures helps make cleaning the tooth easier and stops the accumulation of plaque biofilm, so a high viscosity glass ionomer cement (HVGIC) is used to seal these teeth, covering the pits and fissures. This is done by cleaning the tooth, placing a layer of HVGIC over the back teeth and using finger pressure to keep it in place and dry until the HVGIC material sets. Excess material is removed. If necessary, it is adjusted to fit the bite using hand instruments.[ citation needed ]

Restorative

Where the enamel (the hard outer surface of the tooth) has cavitated or even has a small breach due to tooth decay, the cavity can be enlarged with special hand instruments when necessary to enable access to the soft decayed tooth tissue. After removing as much decay as necessary, the cavity is cleaned with water, dried and filled with the HVGIC. The filling seals the cavity preventing food debris and dental plaque stagnating inside the cavity. It also promotes remineralisation of the dental tissues affected by decay. When the cavity is sealed any decay and bacteria that has been left on the floor of the cavity cannot get access to oxygen and sugar and will not continue.[ citation needed ]

Effectiveness of sealants

  1. The retention rate of ART sealants using HVGIC [8] has improved significantly compared to low and medium viscosity-viscosity glass-ionomers previously used. [9]
  2. ART sealants appear to have a high caries preventive effect. [10]
  3. ART/HVGIC sealants are effective in controlling dentine-carious-lesion development in pits and fissures. [1]
  4. Occurrence of secondary carious lesions are rare at the tooth-restoration interface of single-surface ART/HVGIC restorations in primary teeth. [1]

ART sealants versus resin-based sealants

  1. Compared to resin composite sealants, ART/HVGIC sealants appear to be more effective in erupting permanent molars where moisture control is hard to achieve due to the water-like nature of the glass-ionomer material and less sensitive technique. [11] However, moisture control should always be attempted as much as possible for a better material survival.
  2. The full- and partial-retention survival of ART/HVGIC is lower compared to resin-based sealants. [11]
  3. 4 systematic reviews and meta-analyses, one of which is a Cochrane review. show that there is no difference in terms of dentine caries-lesion preventive effects between both types of sealants. [11] [12] [13] [14] [15]

Indications

ART fillings can be used in multiple situations, such as for single-surface cavities in primary (baby teeth) and permanent (adult) teeth, and multiple-surface cavities in primary teeth, if no other option is available or suitable (e.g. Hall Technique). They can also be used for non-frankly cavitated lesions (presenting a shadow under the enamel) that are not suitable for sealing. In addition, the procedure is particularly suitable for children, uncooperative, disabled and anxious patients. [7] [16]

Contraindications

ART fillings should not be used when there is: [7] [16]

  1. Swelling or a fistula near the decayed tooth;
  2. Pulpal exposure (the nerve of the tooth is visible);
  3. History of pain from the teeth to be treated;
  4. Lesions that cannot be accessed with hand instruments (proximal side);
  5. Multi-surface cavities in permanent teeth; and
  6. Teeth that are badly broken down, which are unrestorable.

Effectiveness

  1. ART is effective for restoring single-surface cavities in both primary and permanent dentition and should be considered as the preferred option. [10]
  2. ART shows higher failure rates for multi-surface carious lesions restorations when compared to single-surface lesions. [1] Meta-analysis concluded that the mean annual failure rate for multiple-surface ART restorations in primary teeth are still high. [9]
  3. Very few studies have investigated the survival (success) of ART restorations in multiple-surface cavities in permanent teeth, and it is not possible to draw conclusions yet. [10]
  4. ART preserves the tooth structure as only the soft demineralised tissue in deep cavities is removed. [5] [6]
  5. Low pain and discomfort are experienced. Dental anxiety is lower when performing ART when compared to conventional drill-and-fill methods. [3] [17] [18]

Comparison with conventional fillings

  1. Systematic reviews and meta-analyses show that there are no differences between ART/HVGIC restorations in terms of longevity in primary teeth (for both single- and multiple-surface lesions) compared to the conventional methods using either amalgam [19] [20] [21] or resin composite. [22] [23]
  2. Systematic reviews and meta-analyses have shown that there are no differences between ART restorations for single-surface lesions in permanent teeth when compared to conventional filling methods. [19] [24] [25]
  3. However, a 2017 Cochrane Review on ART could not draw any conclusions about ART/HVGIC restorations compared to amalgam or composite restoration due to the low quality of the evidence. [26]

Evidence

Below is the summary of success of ART/HVGIC restorations in different type of cavities. [10]

Type of cavities using ART/HVGICEvidence of restoration success
Single-surface in posterior primary teeth (baby back teeth) for first 2 yearsHigh (survival percentage = 94.3% [± 1.5]) [10]
Multiple-surface in posterior primary teeth for first 2 yearsMedium to low (survival percentage = 65.4% [± 3.9]) [10]
Single-surface in posterior permanent teeth (back adult teeth) for first 3 yearsHigh (survival percentage = 87.1% [± 3.2])
Multiple-surface in posterior permanent teethNo conclusion can be drawn due to insufficient data [10]

Although originally developed for use in developing countries, due to its "atraumatic" approach, ART has become increasingly well accepted in developed countries. [27] Although ART alone is insufficient to improve the oral health of people in low- and middle-income countries in a sustainable manner, the World Health Organization (WHO) Collaborating Centre of Oral Health Care Planning and Future Scenarios in Nijmegen has included it in the Basic Package of Oral Care (BPOC). This aims to improve the oral health of deprived communities in a cost-effective manner. This package comprises three components:

ART in multiple-surface cavities

ART/HVGIC restorations can be successfully used in single-surface lesions in both primary (SDCEP) [29] and permanent teeth. [1] For multi-surface lesions (tooth decay that has spread across more than one surface of the tooth), systematic reviews and meta-analyses show that the mean failure rate of ART/HVGIC restorations is higher than occlusal lesions and with a wide range of success. [10] In these cases, there is evidence that the Hall Technique may be more successful.[ citation needed ]

As for multiple-surface cavities in posterior permanent teeth, there is insufficient data to draw conclusions about its use and effectiveness. Therefore, in this case, alternative treatments should be attempted. These might include selective caries removal followed by restoration using conventional filling materials (usually resin composite) depending on the clinical situation. [29]

Advantages and limitations

Advantages

Reasons for using hand instruments

[30]

Reasons for using HVGIC

Limitations

[30]

In combination with other approaches

Use with conditioner

HVGIC has been proven to perform better when a dentine conditioner (cavity conditioner; GC) [45] [46] in used prior to placement of the restorative material. The conditioner is made up of 20% polyacrylic acid and 3% aluminum chloride hexahydrate. It helps to improve the bonding of GIC to the tooth surface by eliminating the smear layer and debris. [47] It also has the advantage of sealing the dentinal tubules to eliminate sensitivity. [47]

Chemo-mechanical approach

This approach comprises the use of chemical material (e.g. Papacarie and Carisolv) which contains enzymes and proteases that soften the decayed tooth structure before removing the decay mechanically. [48] [49] [50] [51] [52] [53] In ART, these chemical materials can be used in conjunction with hand instruments while removing dental caries as they have the advantage of improving treatment comfort by reducing the pain, heat and vibration experienced, and making ART more accepted for children. [54] [55]

Examples of use in different countries

Brazil [56] Atraumatic restorative treatment (ART) for a disadvantaged Brazilian community:

"Training oral health personnel in October 2001, three oral health teams were included in the Family Health Programme in this area. These teams and other dentists in the public health network were trained by a university teacher in the area, to perform ART restorations using glass ionomer cement."

South Africa [57] Introducing the atraumatic restorative treatment (ART) approach in Liberian Refugee Services:

"In 1997, twelve lay refugees in the Liberian refugee camp were trained in basic oral health care including ART according to WHO training module. This primary oral health programme for refugees were revisited after 3 years in December 1999. The 12 trained refugees maintained an oral health clinic in the camp, where patients were treated with ART."

Sri Lanka [58] [59] Atraumatic restorative treatment (ART) programme in Sri Lanka (based on WHO 2008 Oral Health Database):

"Once a month a team of dentists and about 10 dental students from the Division of Community Dentistry visit a primary school in the Kandy area. The faculty receive requests from the Principals of schools, mainly from impoverished areas where the schoolchildren otherwise will not receive any dental care. The students, supervised by the doctors, carry out the examination and treatment in a well-lit classroom or outside in the school premises. While the children are waiting for treatment, they are given oral health education by the dental students. ART is carried out on about 25-30 children on one visit. Around 250 students are provided with ART per year."

Turkey [60] Atraumatic restorative treatment (ART) programme in some rural areas of Turkey:

"From year 1997, dentists and often dental students visit the rural areas including Bagivar, a small town in Anatolia. ART restorations are performed in school children, farm worker’s children living in tents or children working in cotton fields."

In minimal intervention dentistry

ART in minimal intervention dentistry ART in Minimally Intervention Dentistry.png
ART in minimal intervention dentistry

ART is one part of the minimal intervention dentistry (MID) concept and is minimally invasive. It consists of both preventive and restorative components. In ART, the preventive component involves using ART sealants for vulnerable pits and fissures of teeth, whereas the restorative treatment part of the MID involves selective removal of the infected dentine using hand instruments while conserving the affected dentine that can be remineralized, preserving as much tooth structure as possible. This is followed by cavity restoration with HVGIC.

Related Research Articles

<span class="mw-page-title-main">Tooth decay</span> Deformation of teeth due to acids produced by bacteria

Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors, from yellow to black. Symptoms may include pain and difficulty eating. Complications may include inflammation of the tissue around the tooth, tooth loss and infection or abscess formation. Tooth regeneration is an on-going stem cell based field of study that is trying to reverse the effects of decay, unlike most current methods which only try to make dealing with the effects easier.

Dental products are specially fabricated materials, designed for use in dentistry. There are many different types of dental products, and their characteristics vary according to their intended purpose.

Dental restoration, dental fillings, or simply fillings are treatments used to restore the function, integrity, and morphology of missing tooth structure resulting from caries or external trauma as well as to the replacement of such structure supported by dental implants. They are of two broad types—direct and indirect—and are further classified by location and size. A root canal filling, for example, is a restorative technique used to fill the space where the dental pulp normally resides.

Dental sealants are a dental treatment intended to prevent tooth decay. Teeth have recesses on their biting surfaces; the back teeth have fissures (grooves) and some front teeth have cingulum pits. It is these pits and fissures that are most vulnerable to tooth decay because food and bacteria stick in them and because they are hard-to-clean areas. Dental sealants are materials placed in these pits and fissures to fill them in, creating a smooth surface which is easy to clean. Dental sealants are mainly used in children who are at higher risk of tooth decay, and are usually placed as soon as the adult molar teeth come through.

<span class="mw-page-title-main">Dental abrasion</span> Medical condition

Abrasion is the non-carious, mechanical wear of tooth from interaction with objects other than tooth-tooth contact. It most commonly affects the premolars and canines, usually along the cervical margins. Based on clinical surveys, studies have shown that abrasion is the most common but not the sole aetiological factor for development of non-carious cervical lesions (NCCL) and is most frequently caused by incorrect toothbrushing technique.

<span class="mw-page-title-main">Inlays and onlays</span> Restoration procedure in dentistry

In dentistry, inlays and onlays are used to fill cavities, and then cemented in place in the tooth. This is an alternative to a direct restoration, made out of composite, amalgam or glass ionomer, that is built up within the mouth.

<span class="mw-page-title-main">Early childhood caries</span> Dental disease of young children

Early childhood caries (ECC), formerly known as nursing bottle caries, baby bottle tooth decay, night bottle mouth and night bottle caries, is a disease that affects teeth in children aged between birth and 71 months. ECC is characterized by the presence of 1 or more decayed, missing, or filled tooth surfaces in any primary tooth. ECC has been shown to be a very common, transmissible bacterial infection, usually passed from the primary caregiver to the child. The main bacteria responsible for dental cavities are Streptococcus mutans (S.mutans) and Lactobacillus. There is also evidence that supports that those who are in lower socioeconomic populations are at greater risk of developing ECC.

Dentin hypersensitivity is dental pain which is sharp in character and of short duration, arising from exposed dentin surfaces in response to stimuli, typically thermal, evaporative, tactile, osmotic, chemical or electrical; and which cannot be ascribed to any other dental disease.

<span class="mw-page-title-main">Glass ionomer cement</span> Material used in dentistry as a filling material and luting cement

A glass ionomer cement (GIC) is a dental restorative material used in dentistry as a filling material and luting cement, including for orthodontic bracket attachment. Glass-ionomer cements are based on the reaction of silicate glass-powder and polyacrylic acid, an ionomer. Occasionally water is used instead of an acid, altering the properties of the material and its uses. This reaction produces a powdered cement of glass particles surrounded by matrix of fluoride elements and is known chemically as glass polyalkenoate. There are other forms of similar reactions which can take place, for example, when using an aqueous solution of acrylic/itaconic copolymer with tartaric acid, this results in a glass-ionomer in liquid form. An aqueous solution of maleic acid polymer or maleic/acrylic copolymer with tartaric acid can also be used to form a glass-ionomer in liquid form. Tartaric acid plays a significant part in controlling the setting characteristics of the material. Glass-ionomer based hybrids incorporate another dental material, for example resin-modified glass ionomer cements (RMGIC) and compomers.

<span class="mw-page-title-main">Fluoride varnish</span> Highly concentrated form of fluoride

Fluoride varnish is a highly concentrated form of fluoride that is applied to the tooth's surface by a dentist, dental hygienist or other dental professional, as a type of topical fluoride therapy. It is not a permanent varnish but due to its adherent nature it is able to stay in contact with the tooth surface for several hours. It may be applied to the enamel, dentine or cementum of the tooth and can be used to help prevent decay, remineralise the tooth surface and to treat dentine hypersensitivity. There are more than 30 fluoride-containing varnish products on the market today, and they have varying compositions and delivery systems. These compositional differences lead to widely variable pharmacokinetics, the effects of which remain largely untested clinically.

<span class="mw-page-title-main">Remineralisation of teeth</span>

Tooth remineralization is the natural repair process for non-cavitated tooth lesions, in which calcium, phosphate and sometimes fluoride ions are deposited into crystal voids in demineralised enamel. Remineralization can contribute towards restoring strength and function within tooth structure.

Minimal intervention (MI) dentistry is a modern dental practice designed around the principal aim of preservation of as much of the natural tooth structure as possible. It uses a disease-centric philosophy that directs attention to first control and management of the disease that causes tooth decay—dental caries—and then to relief of the residual symptoms it has left behind—the decayed teeth. The approach uses similar principles for prevention of future caries, and is intended to be a complete management solution for tooth decay.

<span class="mw-page-title-main">Enamel hypoplasia</span> Medical condition

Enamel hypoplasia is a defect of the teeth in which the enamel is deficient in quantity, caused by defective enamel matrix formation during enamel development, as a result of inherited and acquired systemic condition(s). It can be identified as missing tooth structure and may manifest as pits or grooves in the crown of the affected teeth, and in extreme cases, some portions of the crown of the tooth may have no enamel, exposing the dentin. It may be generalized across the dentition or localized to a few teeth. Defects are categorized by shape or location. Common categories are pit-form, plane-form, linear-form, and localised enamel hypoplasia. Hypoplastic lesions are found in areas of the teeth where the enamel was being actively formed during a systemic or local disturbance. Since the formation of enamel extends over a long period of time, defects may be confined to one well-defined area of the affected teeth. Knowledge of chronological development of deciduous and permanent teeth makes it possible to determine the approximate time at which the developmental disturbance occurred. Enamel hypoplasia varies substantially among populations and can be used to infer health and behavioural impacts from the past. Defects have also been found in a variety of non-human animals.

Dental compomers, also known as polyacid-modified resin composite, are used in dentistry as a filling material. They were introduced in the early 1990s as a hybrid of two other dental materials, dental composites and glass ionomer cement, in an effort to combine their desirable properties: aesthetics for dental composites and the fluoride releasing ability for glass ionomer cements.

Dentistry for babies is a branch of pediatric dentistry provided to children from birth to around 36 months of age, aiming to maintain or re-establish a good oral health status and create a positive attitude in parents and children about dentistry. Although concerns about dental treatment directed to babies have been reported at the beginning of the twentieth century, only recently has the dental community started to focus on this area of dentistry, due to the high dental caries (decay) prevalence observed in young children.

The Hall Technique is a minimally-invasive treatment for decayed baby back (molar) teeth. Decay is sealed under preformed crowns, avoiding injections and drilling. It is one of a number of biologically oriented strategies for managing dental decay.

<span class="mw-page-title-main">Pulp capping</span> Dental restoration technique

Pulp capping is a technique used in dental restorations to protect the dental pulp, after it has been exposed, or nearly exposed during a cavity preparation, from a traumatic injury, or by a deep cavity that reaches the center of the tooth, causing the pulp to die. Exposure of the pulp causes pulpitis. The ultimate goal of pulp capping or stepwise caries removal is to protect a healthy dental pulp, and avoid the need for root canal therapy.

Silver diammine fluoride (SDF), also known as silver diamine fluoride in most of the dental literature, is a topical medication used to treat and prevent dental caries and relieve dentinal hypersensitivity. It is a colorless or blue-tinted, odourless liquid composed of silver, ammonium and fluoride ions at a pH of 10.4 or 13. Ammonia compounds reduce the oxidative potential of SDF, increase its stability and helps to maintain a constant concentration over a period of time, rendering it safe for use in the mouth. Silver and fluoride ions possess antimicrobial properties and are used in the remineralization of enamel and dentin on teeth for preventing and arresting dental caries.

<span class="mw-page-title-main">Molar incisor hypomineralisation</span> Medical condition

Molar incisor hypomineralisation (MIH) is a type of enamel defect affecting, as the name suggests, the first molars and incisors in the permanent dentition. MIH is considered a worldwide problem with a global prevalence of 12.9% and is usually identified in children under 10 years old. This developmental condition is caused by the lack of mineralisation of enamel during its maturation phase, due to interruption to the function of ameloblasts. Peri- and post-natal factors including premature birth, certain medical conditions, fever and antibiotic use have been found to be associated with development of MIH. Recent studies have suggested the role of genetics and/or epigenetic changes to be contributors of MIH development. However, further studies on the aetiology of MIH are required because it is believed to be multifactorial.

<span class="mw-page-title-main">Non-carious cervical lesions</span> Dental condition

Non-carious cervical lesions (NCCLs) are a group of lesions that are characterised by a loss of hard dental tissue at the cementoenamel junction (CEJ) region at the neck of the tooth, without the action of microorganisms or inflammatory processes. These lesions vary in shape from regular depressions that look like a dome or a cup, to deep wedge-shaped defects with the apex pointing inwards. NCCLs can occur either above or below the level of the gum, at any of the surfaces of the teeth.

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  26. 1 2 Dorri M, Dunne SM, Walsh T, Schwendicke F, et al. (Cochrane Oral Health Group) (November 2015). "Micro-invasive interventions for managing proximal dental decay in primary and permanent teeth". The Cochrane Database of Systematic Reviews. 2015 (11): CD010431. doi:10.1002/14651858.CD010431.pub2. PMC   8504982 . PMID   26545080.
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  29. 1 2 "Prevention and Management of Caries in Children". Scottish Dental Clinical Effectiveness Program 1st and 2nd editions. 2010 (updated 2018).
  30. 1 2 3 4 5 Frencken JE, Pilot T, Songpaisan Y, Phantumvanit P (September 1996). "Atraumatic restorative treatment (ART): rationale, technique, and development". Journal of Public Health Dentistry. 56 (3 Spec No): 135–40, discussion 161–3. doi:10.1111/j.1752-7325.1996.tb02423.x. PMID   8915958.
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  32. ↑ "Alliance for a Cavity-Free Future". 2010. pp. 1–5.
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  34. ↑ Mickenautsch S, Frencken JE, van't HM (June 2007). "Atraumatic restorative treatment and dental anxiety in outpatients attending public oral health clinics in South Africa". Journal of Public Health Dentistry. 67 (3): 179–84. doi:10.1111/j.1752-7325.2007.00017.x. PMID   17899905.
  35. 1 2 Schriks MC, van Amerongen WE (February 2003). "Atraumatic perspectives of ART: psychological and physiological aspects of treatment with and without rotary instruments". Community Dentistry and Oral Epidemiology. 31 (1): 15–20. doi:10.1034/j.1600-0528.2003.00021.x. PMID   12542428.
  36. ↑ Honkala S, Honkala E (May 2002). "Atraumatic dental treatment among Finnish elderly persons". Journal of Oral Rehabilitation. 29 (5): 435–40. doi:10.1046/j.1365-2842.2002.00903.x. PMID   12028490.
  37. ↑ Steele J (June 2007). "ART for treating root caries in older people". Evidence-Based Dentistry. 8 (2): 51. doi: 10.1038/sj.ebd.6400497 . PMID   17589492. S2CID   31283867.
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  39. ↑ Yip HK, Smales RJ (April 2002). "Glass ionomer cements used as fissure sealants with the atraumatic restorative treatment (ART) approach: review of literature". International Dental Journal. 52 (2): 67–70. doi: 10.1111/j.1875-595X.2002.tb00602.x . PMID   12013252.
  40. ↑ Tonmukayakul U, Arrow P (February 2017). "Cost-effectiveness analysis of the atraumatic restorative treatment-based approach to managing early childhood caries". Community Dentistry and Oral Epidemiology. 45 (1): 92–100. doi:10.1111/cdoe.12265. PMID   27859533. S2CID   20303481.
  41. ↑ Leal SC, Abreu DM, Frencken JE (2009). "Dental anxiety and pain related to ART". Journal of Applied Oral Science. 17 (special issue): 84–8. doi:10.1590/S1678-77572009000700015. PMC   5467370 . PMID   21499661.
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  43. ↑ Frencken JE, Holmgren CJ (December 1999). "How effective is ART in the management of dental caries?". Community Dentistry and Oral Epidemiology. 27 (6): 423–30. doi:10.1111/j.1600-0528.1999.tb02043.x. PMID   10600076.
  44. ↑ Phantumvanit P, Songpaisan Y, Pilot T, Frencken JE (September 1996). "Atraumatic restorative treatment (ART): a three-year community field trial in Thailand--survival of one-surface restorations in the permanent dentition". Journal of Public Health Dentistry. 56 (3 Spec No): 141–5, discussion 161–3. doi:10.1111/j.1752-7325.1996.tb02424.x. PMID   8915959.
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  47. 1 2 Raggio DP, Sônego FG, Camargo LB, Marquezan M, Imparato JC (October 2010). "Efficiency of different polyacrylic acid concentrations on the smear layer, after ART technique, by Scanning Electron Microscopy (SEM)". European Archives of Paediatric Dentistry. 11 (5): 232–5. doi:10.1007/BF03262753. PMID   20932397. S2CID   24562984.
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  50. ↑ Hamama HH, Yiu CK, Burrow MF, King NM (2015-06-01). "Systematic Review and Meta-Analysis of Randomized Clinical Trials on Chemomechanical Caries Removal". Operative Dentistry. 40 (4): E167-78. doi: 10.2341/14-021-LIT . PMID   26167737.
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  52. ↑ Keenan AV, Congiusta MA (June 2016). "Efficacy of using Carisolv in the removal of decayed tooth structure in primary teeth". Evidence-Based Dentistry. 17 (2): 44–5. doi:10.1038/sj.ebd.6401167. PMID   27339236. S2CID   22101423.
  53. ↑ Deng Y, Feng G, Hu B, Kuang Y, Song J (July 2018). "Effects of Papacarie on children with dental caries in primary teeth: a systematic review and meta-analysis". International Journal of Paediatric Dentistry. 28 (4): 361–372. doi:10.1111/ipd.12364. PMID   29682851. S2CID   5077509.
  54. ↑ Bussadori SK, Castro LC, Galvão AC (January 2006). "Papain gel: a new chemo-mechanical caries removal agent". The Journal of Clinical Pediatric Dentistry. 30 (2): 115–9. doi:10.17796/jcpd.30.2.xq641w720u101048. PMID   16491964.
  55. ↑ Bussadori SK, Guedes CC, Bachiega JC, Santis TO, Motta LJ (April 2011). "Clinical and radiographic study of chemical-mechanical removal of caries using Papacárie: 24-month follow up". The Journal of Clinical Pediatric Dentistry. 35 (3): 251–4. doi:10.17796/jcpd.35.3.75803m02524625h5. PMID   21678665.
  56. ↑ "Brazil - Atraumatic Restorative Treatment for a disadvantaged Brazilian Community". Malmo University: Oral Health Country/ Area Profile Project. Retrieved 25 June 2020.
  57. ↑ "South Africa - An Atraumatic Restorative Treatment (ART) Project: Activity Report". Malmo University: Oral Health Country/ Area Profile Project. Retrieved 25 June 2020.
  58. ↑ "Sri Lanka - ART Training Programme for School Dental Therapists, Jaffna". Malmo University: Oral Health Country/ Area Profile Project. Retrieved 25 June 2020.
  59. ↑ "Sri Lanka - An ongoing school-based ART Programme". Malmo University: Oral Health Country/ Area Profile Project. Retrieved 25 June 2020.
  60. ↑ "Turkey - Ongoing Atraumatic Restorative Treatment (ART) Programme in some rural areas". Malmo University: Oral Health Country/ Area Profile Project. Retrieved 25 June 2020.
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