Atraumatic restorative treatment (ART) 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 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) caused by dental caries.
In shallow/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 2/3 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); 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 supporting it.
Background and history
ART was firstly introduced by the dentist Jo Frencken in 1985. 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/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 filing 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.
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.
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.
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)