Introduction

Worldwide, the epidemiological distribution of dental caries

is very variable. While there was a decrease in the preva-

lence of dental caries in some developed countries, in some

developing countries this prevalence is still a great concern

[Antunes et al., 2005]. In the latter, the majority of people live

under precarious conditions and have difficulty accessing

dental treatment.

The Brazilian National Household Health Survey [PNAD, 2003] estimated that approximately 28 million Brazilian indi-viduals had never received any dental care (15.9%). In urban and rural populations, such proportions reached 13.6% and 28.0%, respectively. Also, an important imbalance was observed in the distribution of dentists throughout the Brazil-ian national territory.

The main possible reasons for the lack of access to dental care could be: economic barrier, lack and maldistribution of human and material resources, pain and fear, as well as dependency on conventional treatment models which require dental clinics and expensive electronic equipments. From the patients’ point of view, the barriers to restorative treatment include receiving no advice from the dentist, lack of knowledge on restorative care, lack of habits for attending dental check-ups, and negative past experience with dental treatment [Kikwilu et al., 2009a]. Such facts depict the need for more adequate approaches to dental treatment that can be available to a greater part of the population.

It is well-known that the implementation of atraumatic restorative treatment (ART) may help overcome barriers associated to dental treatment, bringing substantial improve-ments for the population’s oral health [Kikwilu et al., 2009b]. The ART technique basically involves removal of soft carious tissue with hand instruments and sealing the cavities and surrounding fissures with an adhesive fluoride-releasing material – glass ionomer cement [van’t Hof et al., 2006]. This technique’s relative simplicity allows pain control, rendering local analgesia normally unnecessary [de Menezes Abreu et al., 2011]. Therefore, anxiety levels are generally reduced and patients are able to cooperate more during clinical pro-cedures [Schriks and van Amerongen, 2003; Frencken et al., 2004]. Moreover, it makes it possible to carry out dental procedures in areas without electricity and conventional dental equipment, reducing considerably the treatment cost. For such reasons, it has been the focus of recent scientific research in many countries [Frencken et al., 2004 and 2007; van’t Hof et al., 2006; de Amorim et al., 2011].

However, despite all this evidence, the implementation of ART presents great difficulties worldwide [Mickenautsch et al., 2007]. One plausible reason for the heterogeneous clinical protocols in Brazil is the lack of knowledge of this evidence by clinicians and especially by senior lecturers that should be spreading the approach. The teaching of ART in universities is the key for enabling dentists to provide an adequate dental treatment for the population. One study that was conducted in Brazilian universities, showed that 73% of the evaluated dental schools include ART teaching in their curricula [Massara, 2010]. Nevertheless, no association was performed in this study to ascertain how ART is taught.

Abstract

AIM: To evaluate the degree of knowledge, use and teaching of atraumatic restorative treatment (ART) of paediatric dentistry lecturers in dental schools through-out 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 regres-sion 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 regu-larly (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.

Key words: Atraumatic Restorative Treatment (ART), Paediatric dentistry lecturers, Dental education.Postal address: D.P. Raggio, Av Lineu Prestes, 2227 - 05508-000 São Paulo SP, Brazil.

Email: danielar@usp.br

L.B. Camargo*, C. Fell**, G.C. Bonini**, M. Marquezan***, J.C.P. Imparato****, F.M. Mendes****, D.P. Raggio*****Faculdade de Odontologia Universidade Paulista, Campinas. **Faculdade de Odontologia São Leopoldo Mandic, Campinas. ***Universidade Federal de Santa Maria. ****Department of Pediatric Dentistry, Faculdade de Odontologia da Universidade de São Paulo; Brazil.

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

European Archives of Paediatric Dentistry 12 (Issue 6). 2011 303

L.B. Camargo et al.

Studies regarding the level of concern of dental lecturers in relation to alternative techniques, that take into account the country’s socio-economic situation and needs, are neces-sary. Thus, the purpose of this study was to evaluate the Paediatric Dentistry education of ART throughout Brazilian dental schools correlating such information with several independent variables.

Methods

This study was previously approved by an University of São Paulo Ethical Board. The structured questionnaire used in our research had been assembled specially for this purpose and contained personal questions such as: age, gender, Brazilian region, time elapsed since graduation (TG), academic back-ground (specialisation courses, MSc, PhD etc) and mainly occupation (exclusively as a senior lecturer, public service as dentist, private office as dentist). Regarding ART, the question-naire comprised questions such as if the senior lecturer used ART or not; how did they use ART (as a restorative treatment or

as urgent/temporary treatment); reason for using (because it is a more conservative approach, because it is a faster treatment, or because other techniques did not work); how often did they use the restorative technique and patient age indication (if there is an age limitation or not).

For sample selection, the Federal Dental Council was contacted and a list of addresses and telephone numbers of undergraduate dental courses in Brazil was obtained. After verifying the exist-ence of the courses, an initial contact was made via electronic mail, regular mail or telephone. Next, the research material was prepared and it consisted of a letter explaining the purpose of the study, a questionnaire marked with an identification num-ber, a consent form for participants to sign, a sealed envelope and a letter to the Paediatric Dentistry co-ordinators asking for their contribution in the process of distributing and returning the questionnaires. The material was sent to 721 lecturers of Paediatric Dentistry of Brazilian Universities in two steps. First, the envelopes were posted and their return waited for 30 days. Afterwards, a second contact was made via e-mail to those

Table 1. Distribution of the 280 lecturers who teach ART according to age group, gender, time elapsed since graduation, educational background, country region, material, reason for using and indication.

Variable Category Teach ART N (%)

Age group 20 to 39 years 111 (39.6)

Over 40 years 169 (60.4)

Gender Male 69 (24.6)

Female 211 (75.4)

Time since graduation <15 years 132 (47.1)

>15 years 148 (52.9)

Country region Southeast 163 (58.2)

Mid-West 16 (5.7)

South 62 (22.1)

North 13 (4.6)

Northeast 26 (9.3)

Educational background Graduation/Specialisation 50 (17.9)

MD/PhD/Post-Doc 230 (82.1)

Material Highly viscous GIC 70 (25)

Other materials 177 (63.2)

No answer 33 (11.8)

Reason for using ART Other technique`s failures/fast treatment 108 (38.60)

Conservative technique 172 (61.4)

Indication Emergency/Temporary 105 (37.5)

Restorative 141 (50.4)

No answer 34 (12.1)

Use ART Use ART 200 (71.4)

Don´t use ART 80 (28.6)

Occupation Teaching 138 (49.3)

Teaching and other 142 (50.7)

European Archives of Paediatric Dentistry 12 (Issue 6). 2011304

Teaching ART for undergraduates

institutions that had not returned the research material, in order

to certify that they had received it and return the material. When

all the data had been collected, descriptive statistical tests and

Poisson regression analyses were conducted with robust vari-

ance to verify associations between exploratory variables and

the use of ART (α=5%). The Stata 8.0 software (Stata Corpora-

tion, College Station, USA) was used.

Results

Approximately 40% of the 721 questionnaires sent were

returned (n=285). Of the lecturers interviewed, 98.2% teach and

1.8% do not teach ART (n=5). Table 1 shows the distribution of

data for the 280 lecturers who teach ART.

Tables 2-4 present data concerning the knowledge of dental lec-turers who teach ART. In the multiple regression model, for the question about indications for ART (emergency/temporary ver-sus restorative treatment), a significant association was found (Table 2) for the lecturers in the Mid-West and Northeast regions (PR=1.66; CI:1.13-2.45; PR=1.33; CI:1.02-1.72 respectively) and lecturers who used ART regularly (PR=3.73; CI:2.11-5.59). Professionals from these regions taught ART as a restorative treatment. When the question was about the reason for using ART (conservative technique versus other techniques e.g. fail-ures/fast treatment), a significant association was found (Table 3) for lecturers with a longer period of TG (time elapsed since graduation) (PR=1.30; CI:1.08-1.56) and also lecturers who used ART regularly (PR=2.87; CI:1.95-4.22), showing that they teach ART as being a more conservative restorative approach.

Table 2. Prevalence ratios calculated in the multiple regression model for Brazilian lecturers who teach for question “ART indications”.

Variable Category N (%) PR CI 95%

Country region Southeast 163 (58.2) 1.00

Mid-West 16 (5.7) 1.66 1.13-2.45

South 62 (22.1) 0.86 0.65-1.13

North 13 (4.6) 1.10 0.74-1.63

Northeast 26 (9.3) 1.33 1.02-1.72

Use Don´t use ART 80 (28.6) 1.00

Use ART 200 (71.4) 3.73 2.11-5.59

Table 3. Prevalence ratios calculated in the multiple regression model for lecturers who answered the question “reason for using ART”.

Variable Category N (%) PR CI 95%

TG <15 years 132 (47.1) 1.00

>15 years 148 (52.9) 1.30 1.08-1.56

Use ART Don´t use ART 80 (28.6)

Use ART 200 (71.4) 2.87 1.95-4.22

Table 4. Prevalence ratios calculated in the multiple regression model for lecturers who answered the question “ART patient age indication”.

Variable Category N (%) PR CI 95%

Gender Male 69 (24.6) 1.00

Female 211 (75.4) 1.26 1.06-1.50

Country region Southeast 163 (58.2) 1.00

Mid-West 16 (5.7) 0.30 0.11-0.80

South 62 (22.1) 0.91 0.80-1.04

North 13 (4.6) 0.93 0.75-1.14

Northeast 26 (9.3) 0.73 0.54-0.96

Use ART Don´t use ART 80 (28.6) 1.00

Use ART 200 (71.4) 1.28 1.06-1.54

Occupation Teaching 138 (49.3) 1.00

Teaching and other 142 (50.7) 0.77 0.68-0.87

European Archives of Paediatric Dentistry 12 (Issue 6). 2011 305

L.B. Camargo et al.

Regarding the patient age covered by ART (versus without age limitation), a significant association was found (Table 4) for women (PR=1.26; CI:1.06-1.50) and lecturers who used ART regularly (PR=1,28; CI:1,06-1,54), indicating that they teach that there is no age restriction to perform ART. A significant association was also found for lecturers and resi-dents of the Mid-West and Northeast regions (PR=0.30; CI: 0.11-0.80; PR=0.73; CI: 0.54-0.96 respectively), indicating that the lecturers from these regions believed that ART has some patient age limitations.

Discussion

Dental caries treatment can sometimes represent a great challenge to professionals. Not all dental diseases can be treated using conventional restorative techniques. Even though conventional ART was originally developed to be used in underprivileged populations who did not have access to dental offices, ART can be adequately applied in private offices in developed countries [Pilot, 1999].

Notwithstanding the low response rate of 40%, a good acceptance of ART was observed, as shown previously in Brazilian dental schools [Massara, 2010]. An option for increasing the response rate and decreasing the bias of obtaining more responses from lecturers who approve ART could be to promote a greater awareness of these lecturers regarding the importance of participating in the research pro-posed. Furthermore, involving other university departments, such as Dentistry or Public Health, could be beneficial for the construction of a current attitude to the use and teaching of ART in Brazil.

An unequal distribution of ART teaching throughout the different regions of Brazil was expected, with a greater fre-quency in underprivileged regions that have a lower number of dentists. The quest for regional development, seeking to reduce social inequalities between regions of Brazil, consti-tutes an immense challenge for the integrated development of the country. The Brazilian Amazon is one of the planet’s most valuable geographic locations, particularly due to its biodiversity; yet from a socio-economic and human stand-point, there are still many challenges to be faced [BHM, 2004]. Considering the great benefits for oral health that could be brought on by the use of ART in the rural popula-tions of the North region, it is important to know whether the lecturers of dental schools in this region use and teach this technique to future dental professionals. Thus, further stud-ies in this region are necessary to reach these professionals and ask if they are performing ART properly after graduation.

In our sample the majority of the lecturers used and taught ART regularly. It was observed that a large number of partici-pants were women and a plausible explanation for this fact is that, in the last few years, there has been a substantial increase in number of female graduate dental school stu-dents [Saliba, 2002].

To assess whether ART is being adequately taught in Brazilians dental schools, data were evaluated considering the lecturers' knowledge regarding the treatment. When analysing the mul-tiple regression model, our study demonstrated that lecturer residents in the Mid-West and Northeast regions and lecturers who used ART regularly taught the ART approach appropri-ately as a definitive restorative treatment. Moreover lecturers with a longer period of TG and also lecturers who used ART regularly, taught accordingly that it is a more conservative treatment. Regarding the patient age covered by ART, a sig-nificant association was found for women and lecturers who used ART regularly that there is no age limit to perform ART.

After complete analysis of the multiple regression model, the variable “use ART regularly” was a determinant for the proper teaching of ART. It is possible that lecturers who use ART regularly present a significant association with correct teach-ing because of the fact that they have also been practicing ART for a longer period of time. It is necessary to emphasise that the restorative technique involved in ART is considered to be operator and technique dependent [Frencken et al., 1998; Komoli et al. 2009; 2010] with the quality and longevity of the restorations varying according to the operator. Hence, it is also possible to suppose that the findings of the present study may be confirming the fact that more experienced and trained dentists achieve better results and, consequently, present higher levels of confidence in the ART approach. Individual experience may vary significantly as they are intimately related to each professional’s level of training and clinical expertise. Perhaps those confident in using ART are also scientifically knowledgeable which further benefits the teaching of ART.

The dentists’ self-perceptions of low levels of clinical skills in performing ART correctly after training are one of the major barriers to implementation of the ART approach in public oral health services [Mickenautsch et al., 2007]. Furthermore, in order to have a successful introduction of ART, people who matter in the daily practice of dental practitioners need to accept and appraise this treatment approach positively [Kik-wilu et al., 2009b].

The use of ART in Public Health Services is recommended by the World Health Organization (WHO) [Frencken et al., 2002; Beiruti, 2005] and may offer many benefits for the population such as access to minimally invasive restorative treatments which generate low levels of stress and require a shorter chair time, thus making it easier to provide the treatment that is demanded. Considering the current concern of Brazilian Den-tal Schools regarding the preparation of future dentists to work in the Public Health System, it is important that lecturers insert ART into their educational programs. According to Frencken et al. [2002], unstructured courses that attempt to train den-tists to execute the ART technique are inappropriate and each government is responsible for deciding which course format is more adequate so that regional circumstances can be taken into account.

European Archives of Paediatric Dentistry 12 (Issue 6). 2011306

Teaching ART for undergraduates

Through the assessment of the interest of lecturers in the use of ART, clarifications regarding the philosophical basis and the restorative technique should be put forth so that each professional may be prepared to deal with the main difficulties that arise when using ART and, thus, achieve the benefits desired in clinical practice, be it public or private. In our study, the lecturers who did not teach ART (n=5) reported that although they did not teach ART, they regularly used the technique in their clinical practices (private office or public health system). However, these professionals had several conceptual errors as to consider ART as an emergency or temporary treatment and to use conventional glass ionomer cement, instead of a high viscous restorative material.

Conclusion

ART has been widely taught in Brazilian dental schools and the regular use of ART by lecturers in their clinical prac-tices positively influences the appropriate teaching of this technique.

Acknowledgments

The authors wish to thank the participants of the Seminars in Paediatric Den-tistry (FOUSP) and all lecturers involved for their time spent in answering the questionnaire.

References

de Amorim RG, Leal SC, Frencken JE. Survival of atraumatic restorative treat-ment (ART) sealants and restorations: a meta-analysis. Clin Oral Investig 2011 Jan 28. [Epub ahead of print].

Antunes JL, Jahn GM, de Camargo MA. Increasing inequalities in the distribu-tion of dental caries in the Brazilian context in Finland. Community Dent Health 2005; 22:94-100.

Beiruti N. Views on oral health care strategies. East Mediterr Health J 2005; 11:209-216.

Brazilian Health Ministry. Available in 2004 from: http://portal.saude.gov.br/portal/ arquivos/pdf/Relato_Saude_Amazonia.pdf.

Frencken JE, Makoni F, Sithole WD, Hackenitz E. Three-year survival of one-surface ART restorations and glass-ionomer sealants in a school oral health programme in Zimbabwe. Caries Res 1998; 32:119-126.

Frencken JE, Holmgren CJ, van Palenstein Helderman WH. Basic Package of Oral Care WHO Collaborating Centre, Nijmegen. 2002; ISBN 9016208-9.

Frencken JE, van´t Hof MA, van Amerongen WE, Holmgren CJ. Effectiveness of single surface ART restorations in the permanent dentition: a meta-analysis. J Dent Res 2004; 83:120-123.

Frencken JE, van´t Hof MA, Taifour D, Al-Zaher I. Effectiveness of ART and traditional amalgam approach in restoring single-surface cavities in pos-terior teeth of permanent dentitions in school children after 6.3 years. Community Dent Oral Epidemiol 2007; 35:207-214.

Kemoli AM, van Amorongen WE, Opinya GN. Influence of the experience of the operator and resistant on the survival rate of proximal ART restora-tions: two year results. Eur Archs Paediatr Dent. 2009; 10(4):227-232.

Kemoli AM, van Amorongen WE, Opinya GN. Influence of different isolation methods on survival of proximal ART restorations in primary molars after two years. Eur Archs Paediatr Dent. 2010; 11(3):136-139.

Kikwilu EN, Frencken JE, Mulder J, Masalu JR. Barriers to restorative care as perceived by dental patients attending government hospitals in Tanzania. Community Dent Oral Epidemiol 2009a; 37:35-44.

Kikwilu EN, Frencken JE, Mulder J, Masalu JR. Dental practitioners` attitudes, subjective norms and intentions to practice Atraumatic Restorative Treat-ment (ART) in Tanzania. J Appl Oral Sci 2009b; 17:97-102.

Massara MLA. Tratamento Restaurador Atraumático no cenário brasileiro. Available in 2010 from: http://www.abodontopediatria.org.br/.

de Menezes Abreu DM, Leal SC, Mulder J, Frencken JE. Pain experience after conventional, atraumatic, and ultraconservative restorative treatments in 6- to 7-yr-old children. Eur J Oral Sci 2011; 119:163-168.

Mickenautsch S, Frencken JE, Van´t Hof MA. Factors inhibiting the implemen-tation of the Atraumatic Restorative Treatment approach in public oral health services in Gauteng province, South Africa. J Appl Oral Sci 2007; 15:1-8.

Pilot T. ART from a global perspective. Community Dent Oral Epidemiol 1999; 27:421-422.

PNAD/IBGE. Available in 2003 from: http://www.ibge.gov.br/home/ presiden-cia/noticias/noticia_impressao.php?id_noticia=370.

Saliba NA, Moimaz SAS, Vilela RM, Blanco MB. Women in dentistry: a quanti-tative analysis. Rev Bras Odontol 2002; 59:40040-2.

Schriks MCM, van Amerongen WE. Atraumatic perspectives of ART: psycho-logical and physiological aspects of treatment with and without rotatory instruments. Community Dent Oral Epidemiol 2003; 31:15–20.

van´t Hof MA, Frencken JE, van Palestein Helderman WH, Holmgren CJ. The atraumatic restorative treatment (ART) approach for managing dental car-ies: a meta-analysis. Int Dent J 2006; 56:345-351.

European Archives of Paediatric Dentistry 12 (Issue 6). 2011 307