DIVERSE FIELDS FOR ATRAUMATIC RESTORATIVE TREATMENT.

Authors: Gustavo F. Molina, Gastón P. Arceguet

INTRODUCTION

Current knowledge regarding caries disease has substantially evolved within the last decade. Understanding of its dynamic lead to a risk factor approach which left the treatment of cavities a minor role to play in the whole planning. Using this background, Minimally Invasive Dentistry (also minimum intervention dentistry - MID) builds its framework over three main principles: 1) Early diagnosis and assessment of caries risk factors; 2) Maximum tissue preservation and 3) Minimally surgical intervention need.1

Decision to intervene depends on the ability to handle caries risk factors in order to enhance oral conditions for a better prognosis of any restoration, using the most suitable materials and methods to sustain what was achieved by means of combining preventive and operative dentistry2.

The Atraumatic Restorative Treatment was developed following the mentioned principles and it is on line with the philosophy of MID. What started as an alternative resource for out-reach situations, it became one of the most flexible methods for caries removal and restoration of the cavity in many private dental offices worldwide3.

Oral health education is certainly the first strategy to be developed, more important than any operative procedure. Individual or community-based oral health planning is absolutely necessary before drilling wholes or sealing fissures, so that caries is focused as a multifactorial disease, instead of a number of lesions to be restored.

MINIMUM INTERVENTION DENTISTRY (MID)

Conceptual basis of MID framing the Atraumatic Restorative approach

A significant number of “coincidences” forced Dentistry to a minimum intervention point: From patients´ perspective, dental fear is related to needles, drills and extractions. That fact made us think over a list of “untouchable truths” which were an essential part of our graduate knowledge, as it is brought for discussion in a very interesting book edited by Professors Albrektsson, Bratthall, Glantz and Lindhe (2001)4.

Back to patients´ needs and demands, a new concept of successful prevention is promoted since each patient decides to live healthy. That makes them responsible for certain actions to improve their standards of oral hygiene, dietary habits, regular visits to a dental office, etc. Dentists should motivate and guide their patients with appropriate information and providing evidence-based treatment options to solve a variety of situations. MID proposes the less professional intervention to put oral health care on patients´ control.

But when intervention is required, current knowledge about chemistry and microbiology of oral cavity is combined with the development of “intelligent” restorative materials such as glass ionomers, in order to achieve the maximum preservation of dental tissues.

Principles for minimally invasive operative treatment in dental caries removal

As a kind of guideline, the following sequence should be taken into consideration:

1) Early diagnosis of carious lesions.2) Evaluación individual del riesgo de caries.3) Preventive strategies.4) Operative treatment.5) Selection of restorative materials.6) Recalls according to individuals´ caries risk category.

1) Early diagnosis of carious lesions.

Clinical diagnosis of carious lesions has been described by Stookey and González-Cabezas5 as a trinity that includes:

Recognition of caries lesions, Determining whether they will progress or not Assessing if more lesions will occur.

Edwina Kidd and Avi Banerjee ironically ask themselves -and, of course, their readers- “what is absence of caries?”, mixing comments about what we were taught and what there is available in dental literature regarding different standpoints and the scientific evidence that supports those theories4. A major disagreement is related to what different dentist may diagnose as a caries lesion, its extension and depth. Multiple tools for early diagnosis have been proposed and assessed by different authors6. One conclusion of these papers analysis is the fact that visual inspection is rather a poor method for early caries detection. Furthermore, magnification and bite wing x-rays could be a great help to enhance results. However, best results are achieved by means of laser fluorescence, despite it is an expensive resource for ordinary diagnosis.

Pictures 1 and 2 show teeth 35, 36 and 37 with caries lesions at different stages. Treatment decision is based on follow ups observations, in order to check how they evolve.

2) Individual caries risk assessment.

A thorough revision of different risk factors is described in a paper by Pitts et al. (1998)7. Chairside methods for the determination of cariogenic bacteria, salivary flow rate and buffer capacity can provide important data for risk evaluation8-11.

Among those risk prediction models that have validated, the cariogram can be mentioned (Bratthall, 1996)12,13. Such tools can help the clinician to structure the information on caries risk and also institute measures directed towards the specific risk situation. The cariogram is an example of a user-friendly program for caries risk evaluation and patient communication. The program is a free-ware available at http://www.db.od.mah.se/car/cariogram/cariograminfo.html .

3) Preventive strategies.

After a careful examination concerning individual or community caries risk factors, preventive strategies should be planned in order to anticipate the occurrence of caries disease, to prevent further complications and sequel or to restore their previous situation14, according to Leavell and Clark levels (1958).

As it was stated, preventive measures could be performed on both a community as well as an individual level, starting with oral health education15. On the public level is awareness about oral hygiene and nutrition important issues as well as the distribution of fluorides16. On the individual level, prevention starts with identifying at what level of risk the specific patient is found.

Picture 3 shows a “tooth-brushing workshop” in a rural community, northwestern Argentina.

4) Operative treatment of carious lesions.

Different alternative methods for caries removal are listed in the following table, according to Noack et al. (2004)17.

Techniques Principles Instruments/materials

a - Excavation techniques

Manual excavation Black´s sharp excavators

Rotary excavation Low and high speed hand pieces

Controlled selective excavation

Torque controlled motors, polymer burs, fluorescence-aided caries excavation

Air abrasión, air polishing

Air pressure device + aluminum oxide

Sonoabrasion Diamond coated tips or brushes. Air scaler hand pieces

Chemo-mechanical excavation

Carisolv system

Enzymatic digestión Proteolitic enzymatic collagen digestion

LASER Technology CO2, Nd YAG, Er YAG

b- Desinfection techniques

Ozone treatment Desinfection with ozone gas

Photodynamic therapy Photoactivated desinfection, combined with Laser

Antibacterial therapy Silverdiamin-F, AgNO3,

Clorhexidine / Tetracycline

c- Sealing techniques Fluoride releasing materials

A.R.T.: Excavators + Glass Ionomer Cements

Dentin Adhesives Hydrophilic systems developed for dentin adhesion

Antibacterial resin materials

Combination of sealing and antibacterial effects

5) Selection of restorative materials.

Current available materials range from conventional amalgam fillings to technologically advanced nanofilled composites, without forgetting the last developed high density glass ionomers.

Each one of those restorative materials provides a number of advantages as well as limitations, that clinicians ought to know for a appropriate selection according to the situation.

Silver amalgams claim to have the best performance in posterior teeth, large class II restorations, using a fast and non-sensitive setting technique. On the other hand, composite resins overcome the latter regarding aesthetic properties and cavity preparations with a maximum preservation of sound tissue.

Glass ionomer cements are well known for their biological tolerance, specific adhesion and fluoride release. Setting technique is less sensitive than composites and they promote a biochemical modification of oral environment18,19.

A.R.T. IN PRIVATE PRACTISE

THIS CHAPTER WILL BE DESCRIBED THOROUGLY WHEN THE COURSE IS AVAILABLE.

Clinical situations

Casos clínicos

Pictures 4 to 7 show a clinical sequence of A.R.T. in a 5 years old boy, as an introduction to a painless dental treatment.

Pictures 8 to 11 show a clinical sequence of A.R.T. in a 12 years old –high caries risk- girl, with a deep lesion in the buccal surface of a recently erupted 37.

A.R.T. IN COMMUNITY DENTISTRY

Caries decline in developed countries contrasts with developing countries trends regarding the disease20. Absence of official policies for high risk populations that are passing through a cultural crisis without any preventive program that may preserve them from exposure to new risk factors regarding caries aethiology, often leads to a great compromise in their oral health status21,22.

The A.R.T. approach includes oral health education as a main strategic component. A previous insight from the community where the program will be applied is necessary to achieve sustainable results23. After this first educational stage, epidemiological data is recorded in order to determine community risk factors for caries disease. At the operative level, selected caries lesions (cavitated dentinal caries without pulpal compromise, preferably one surface cavities , eg. Class I) are treated using manual excavators until the maximum amount of decayed tissue is removed. A high density glass ionomer cement seals the cavity and a follow up is performed every year, checking marginal integrity of the restoration, presence or absence of secondary caries, etc..

Worldwide reports show an acceptable rate of success after 3 years follow ups. More than 70% and up to 95% of acceptable restorations were found in different studies. A list of international programmes is available in the following references: 25-27. Abstracts related to A.R.T. experiences from 1996 to 2004 is also listed in the web site www.midentistry.com.

The authors have been carrying out different programs in Argentina, applied to high risk groups as it is listed in the following table:

Community Period Material Age group

n (survey) % success

Disabled patients

1999A.R.T./FujiIXCarisolv/FIX

4-65 7578,595,3 *

Rural school population

2000 A.R.T./FujiIXCarisolv/FIX

6-12 50 47,885,2 **

Aborigine school

population

2002-2003 KetacMolar 6-14 79 70 ***

* Molina G, Kultje C J Dis Oral Health (2003)

** Molina G, Crosa M Jornada de Operatoria Dental y Biomateriales, Córdoba (2001)

***Arceguet G, Arceguet L, Díaz L, Molina G XXXVII Encuentro anual de la SAIO (2004)

Picture 12: An oral health promotion programme in northwestern argentinean aborigine communities. A.R.T. are performed in a non-conventional setting.

Pictures 13 to 18 : A.R.T. sequence and its one year follow-up. (Iruya, 2003)

Pictures 19 to 21: A.R.T. sequence and its one year follow-up. (Iruya, 2003)

Pictures 22 to 25: A.R.T. sequence and its one year follow-up. (Iruya, 2003)

A.R.T. IN PATIENTS WITH DISABILITY

Caries can be the cause of great distress and suffering in mentally disabled people and their family. Since conventional dental treatment finds numerous difficulties to be applied in many of these patients, alternative methods need to be searched in order to provide non-invasive oral health care to this population.

General nomination of mentally disabled patients comprises a wide spectrum of diverse situations concerning caries experience. Decayed teeth as well as other oral findings vary according to individual factors, which also may depend on the general pathology. Mental retardation is often associated to some physical impairment, which may compromise the ability to chew or to brush the teeth properly. This disadvantage may be compensated in many people with cerebral palsy by supplementary oral hygiene aids, the buffering capacity of saliva or a strong grinding.

A major problem to provide dental care to this population is the ability to cooperate most of these patients show, moreover when dental procedures take too long or are somewhat painful. Ordinary fears to needles, drill and/or other dental instruments add to the list of issues that may complicate the already fragile situation. When the patient cooperates, a paediatric approach is compatible. In some cases, conscious sedation may help to achieve relaxation and to extend working time28. Nevertheless, general anaesthesia is suggested as a last resource if previous options did not succeed. Even when the risks are minimized, the latter alternative may scare those involved in the decision.

Several management options have been suggested for this special group of patients, ranging from remineralisation of decayed tissue to conventional treatment under general anaesthesia (GA). Encouraging results were reported related to Atraumatic Restorative Treatment (A.R.T.) in deprived areas that, in many ways, face similar barriers to dental care compared to dentistry for disabled people.

There are several aspects to the management of caries in mentally disabled patients. Decision to remineralize, restore or extract a tooth is based on evidence such as structural damage and individual patient factors (trigger conditions, risk factors, compliance). It also depends on the combined abilities of patients (and carers) and dentists to successfully control the caries disease2.

According to international dental literature, the discussion turns over the feasibility to provide this group treatment in a general dental practice29,30. In addition, the availability of dental services for special needs patients remains poor in many countries.

The modern concept of minimal intervention appears to be quite suitable to approach caries lesions in mentally disabled patients. Atraumatic Restorative Treatment (A.R.T.) is based on removing tooth decay using hand instruments after which the cleaned cavity is filled with an adhesive material, currently glass ionomer. The administration of local anaesthesia is not required in most cases. This treatment modality is also in line with non-invasive, tissue preserving methods and is proposed as the answer to the unavailability of restorative care for many population groups. Indeed, for mentally disabled patients it certainly is, although there is still a gap to be filled as it is not always possible to remove enough decayed dentine or to achieve an acceptable sealing of the restoration which could both lead to a short term clinical failure31,32.

Many neurologically compromised patients have involuntary associated movements, which may impede a proper accessibility to caries lesions with rotary instruments. Different anatomic structures, particularly the tongue, may also represent a barrier to remove decayed tissue or fill a cavity33. Drooling and the resultant unintentional loss of saliva from the mouth could mainly affect the setting of filling materials that are sensitive to moisture during that critical moment34.

Epidemiological reports agree that the most active decay age ranges from the pre-adolescence to young adulthood (25 years old). Occlusal surfaces are usually affected during this period35,36. As the ability to chew decreases, the occurrence of caries locates in cervical areas increases because of cumulate plaque that cannot be removed by an impaired oral musculature37. The cause for this lesions occurrence, mainly in disabled elders, is due to gingival recession, medication, poor oral hygiene or an impaired oral musculature which enables a proper autoclisis.

Combination with A.R.T. principles may result in a successful procedure not only in the gingival area but also in occlusal deciduous and permanent tooth surfaces. Furthermore, the efficacy of the gel allows the excavation of deep carious lesions according to the “step-wise” technique38 without using local anaesthesia. Adverse effects have not been reported neither in hard nor in soft tissues. At this stage, clinical failure of the restorations could be related to a number of different factors despite of the efficacy of the caries removal method, such as individual caries activity and grinding or the setting of the restorative material39.

A judicious selection of the filling material will ensure an acceptable clinical performance of the restoration. However, it is quite realistic to consider that sensitive techniques are not suitable in many patients with physical and/or intellectual disabilities and this may be another reason that explains the number of complications at follow-up.

One study carried out by our team shows the importance of achieving a caries free surface before restoring the cavity – only in non-caries free cavities the filling was lost, irrespective of treatment method (A.R.T. 19 not caries free, 6 lost fillings; A.R.T.+Carisolv 8 not caries free, 2 lost fillings). However, if lost fillings were correlated to caries free at the original treatment, there was no significant difference between the groups40.

Casos clínicos

Pictures 26 to 36: A 17 years old girl with neuromuscular alteration. Teeth 11, 21 y 23 are affected by caries lesions without pulpal compromise. A.R.T. with Carisolv is applied. Restoration was finished with Vitremer (3M Espe). Last two pictures show a 5 years follow-up.

Pictures 37 to 43: A 26 years old young lady with neurological damage because of a car accident. Multiple cervical lesions have developed because of poor oral functions after a long post-coma period. A.R.T. was applied in inferior premolars and molars, filled with Fuji IX (GC International). One year follow-up.

Pictures 44 to 50: Deep occlusal lesions in a 19 years old young man with a neuromuscular alteration. A.R.T. is performed in tooth 46 and filled with Ketac Molar (3M Espe).

ATRAUMATIC RESTORATIVE TREATMENT HISTOLOGICAL CUTS

Pictures 51 to 54: In vitro microleakage study of lesions treated with A.R.T. Ketac Molar (3M Espe).

CONCLUSIONS

Supported by a considerable advantages such as painless procedure, non-sensitive technique, reasonable relationship cost-benefits, feasible and sustainable in out-reach situations, flexible and combinable, etc., the Atraumatic Restorative Treatment approach stands as a excellent alternative method for treating caries lesions in a diverse variety of situations, ranging from rural settings to a modern pediatric clinic. However, it is advisable to not to generate over expectations regarding this technique as it also has limitations. A judicious selection of the cavities and the restorative materials is suggested to achieve better results.

REFERENCES

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