Elsevier

Dental Materials

Volume 26, Issue 1, January 2010, Pages 1-6
Dental Materials

The ART approach using glass-ionomers in relation to global oral health care

https://doi.org/10.1016/j.dental.2009.08.013Get rights and content

Abstract

Dental caries is the most prevalent non-communicable disease in the world. Its management in high-income countries over the last four decades has resulted in relatively low caries prevalence in child and adolescent populations. In low- and middle-income countries, caries management is virtually non-existent and this may lead to serious physical and mental complications, particularly in children. Toothache is predominantly treated by extracting the cavitated tooth. Absence of restorative oral care is partly due to the copying from high-income countries, of restorative treatment reliant on electrically driven equipment and often inappropriate for use in many low- and middle-income countries. Atraumatic Restorative Treatment (ART), which does not rely on electrically driven equipment, has yielded good results over the last two decades. ART uses hand instruments and high-viscosity glass-ionomers. Its introduction into public oral healthcare systems has been piloted in several countries. Initial short-term results show that the introduction of ART, using high-viscosity glass-ionomers, has increased the ratio of restorations to extractions. Moreover, the percentage of ART restorations in relation to the total number of restorations placed increased steeply after its introduction and has remained high. However, ART introduction faced a few barriers, the most important being high patient workloads and the absence of a constant supply of dental instruments and glass-ionomers. High-viscosity glass-ionomer has become an essential element in public oral healthcare systems, particularly in those operating inadequately.

Introduction

Dental caries is the most prevalent non-communicable disease in the world. Its distribution among children, however, is skewed. Caries prevalence is relatively low in high-income, and relatively high in low- and middle-income countries. Children from high-income countries have benefited from the available established caries preventive measures; such as the use of fluoride-containing products and awareness among their parents and caretakers of the importance of keeping tooth surfaces free from plaque. In addition, children who have developed tooth cavities can utilize the well-organized oral healthcare services operating in many high-income countries. Children, adolescents and adults in these countries can comfortably rely, for oral care, on the available healthcare systems, often financed by government and/or private insurance schemes.

The oral healthcare situation for people in low- and middle-income countries is completely different. Not only is the prevalence of dental caries higher and its severity greater; the oral healthcare system is usually insufficiently equipped to provide the needed care. This means that many in these countries suffer in many ways: most carious cavities are not treated restoratively. People with open cavities usually present themselves at a health center or dental clinic when pain is unbearable. Extracting the badly decayed tooth is then the treatment of choice but the prevalent unavailability of restorative care can have serious consequences, especially for children. A study from the Philippines revealed that almost all carious cavities in 6- and 12-year-olds remained untreated and that 40% of these cavities were accompanied by infection of the pulp, abscesses, fistulas and/or infected root remnants [1]. These conditions may pose a serious threat to children's general health, because of the risk of developing systemic sepsis, osteomyelitis and infection of the neck and the floor of the mouth. Furthermore, toothache may alter children's eating and sleeping habits which can affect their growth negatively [2]. Untreated carious cavities in children have also been associated with protein-energy malnutrition [3], [4] and stunted growth [5], and children suffering from early childhood caries have been associated with lower body weight and reduced body length [6].

Untreated carious cavities do not only have an impact on the physical condition of children; but their cognitive development may also become impaired. In a survey of native-American schoolchildren, one third admitted to missing school because of dental pain [7], and 70% of children in the Western Cape, South Africa, had missed school due to toothache [8]. The seriousness of the absence, or low coverage, of oral (restorative) care in many low- and middle-income countries is demonstrated in the case of the Philippines. The country's Department of Education reported toothache as the principal reason for absenteeism from schools [9]. The effect of chronic dental pain in children is not a supposition: affected children are unable to focus and unable to complete school assignments, which affects their school performance negatively [10].

So, why do people in low- and middle-income countries not receive sufficiently organized restorative oral care?

Section snippets

Restorative oral care

In high-income countries, restorative oral care relies on electrically driven equipment and a well-functioning piped water system. The care is provided in a dental clinic building by dental professionals who are generally well paid. Of late, globalization has encouraged dental professionals to travel, mainly for holidays, to low- and middle-income countries. However, a growing number undertake the travel to provide oral care to those in need. The latter group will have encountered an oral

Atraumatic Restorative Treatment (ART)

Over the last two decades a preventive and restorative caries management concept has been developed: Atraumatic Restorative Treatment (ART). ART does not require electricity or piped water systems. It uses hand instruments for opening and cleaning tooth cavities and mainly uses a glass-ionomer to fill the cleaned cavities and to seal caries-prone tooth surfaces [11]. Autocure glass-ionomers are essential in this context as their powder-liquid hand-mixed form is appropriate everywhere in the

Results of investigations on ART

Many researchers from many countries have investigated different aspects of ART. Salient findings from these studies can be summarized as follows:

  • -

    Survival rates of single-surface ART restorations using high-viscosity glass-ionomers in primary and permanent posterior teeth are high and meet the specifications of the American Dental Association (ADA) [15].

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    Survival rates of multiple-surface ART restorations using high-viscosity glass-ionomers in primary posterior teeth do not meet the ADA

ART and glass-ionomers

The first material used in conjunction with the ART approach was a carboxylate cement. This material was soon replaced by a medium-viscosity glass-ionomer in the late eighties. At that time, medium-viscosity glass-ionomers were mainly used for filling cavities in non-stress-bearing situations such as in buccal surfaces, where they survived for long [31]. Given the circumstances in which cavitated teeth were routinely extracted to alleviate pain, filling a hand instruments-cleaned cavity in a

Introduction of ART and glass-ionomer in oral health service systems

Researching ART and glass-ionomers over the last two decades was necessary, to understand the potential and limits of the individual components and their combination. Considering the positive outcomes of the various meta-analyses on ART restorations [15], [16], individual studies and the systematic review of the respective effectiveness of carious lesion prevention of glass-ionomer and composite resin sealants [42], a need arose to introduce ART into oral health care service systems. In the

Conclusion

Although the definition of the Atraumatic Restorative Treatment approach includes the combined use of hand instruments, adhesive systems and adhesive materials, in practice high-viscosity glass-ionomers have turned out to be the adhesive material mainly used. The hand-mixed version allows worldwide ART sealant production and ART restorations in all population groups outside the dental clinics. High-viscosity glass-ionomer is an essential element in oral healthcare systems, particularly in those

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