Procedure for atraumatic restorative treatment
As with any other oral treatment procedure, ART requires a proper patient-to-operator position. This requirement usually is not a problem in a dental surgery, but requires particular attention in other working environments. A number of devices have been developed and one that is very useful is a light weight, cushioned headrest attached to the short end of a table combined with a foldable cushion for the comfort of the person receiving the treatment.
Since its inception, the ART technique has undergone revisions aimed at improving the basic technique. Unlike many other restorative procedures, usually there is no need to give local anesthesia when using the ART technique because temperature induced pain from using a drill is avoided. Because the technique mainly involves the removal of decalcified tooth tissue, pain can be minimized, and often does not occur at all. Thus, fear of dental procedures is reduced.
The principal steps of ART are described below which are based on illustrations in the ART manual.
1. Isolate the tooth with cotton wool rolls. Only the tooth or teeth to be treated need to be isolated. Rationale : It is easier to work in a dry environment than a wet one. Cotton wool rolls are available in all parts of the world.
2. Clean the tooth surface to be treated with a wet cotton wool pellet. Have a small cup of water available. Separate the cotton wool pellets from each other. Then dry the surface with a dry pellet. Rationale : The wet cotton wool pellet removes debris and plaque from the surface, thus improving visibility. The extent of the lesion and any unsupported enamel then can be identified.
3. Widen the entrance of the lesion. This step is necessary only if the entrance is small. Place the working tip of the dental hatchet in the entrance and rotate it backwards and forwards. For opening very small cavities, the corner of the working tip is placed in the cavity first and rotated. Rationale : The hatchet replaces the bur. By rotating the instrument tip, unsupported enamel will break off, creating an opening large enough for the small excavator to enter.
4. Remove caries : Depending on the size of the cavity, use either the small or the medium sized excavator. Remove caries at the dentin-enamel junction before removing caries from the floor of the cavity. If working without an assistant, deposit the soft, excavated caries on the cotton wool roll placed next to the tooth. Thin unsupported enamel can be broken away carefully by placing the hatchet on the enamel and pressing gently downward. Wash the cavity with lukewarm water or a small cotton wool pellet. Rationale : All soft caries should be removed. Thin, often decalcified, unsupported enamel is relatively easy to break off. The enamel and the dentin-enamel junction need to be thoroughly cleaned to prevent caries progression and to obtain a good seal of the coronal part of the restoration. By cleaning the cavity in the proximity of the dentin-enamel junction before that closest to the pulp, any pain caused through the cleaning process is limited to a few moments at the end of cavity preparation.
5. Provide pulpal protection if necessary. This step is used only for very deep cavities and is achieved by applying a setting calcium hydroxide paste to the deeper parts of the floor of the cavity. The cavity floor does not need to be covered completely because it will reduce the area available for adhesion of the filling material. Rationale : Calcium hydroxide stimulates repair of dentin and glass ionomers are biocompatible. In a recent study on the fate of soft caries dentin left under glass ionomer fillings, hardening after seven months was reported.
6. Clean the occlusal surface. All pits and fissures should be clear of plaque and debris as much as possible. Use a probe and a wet pellet for cleaning. Rationale : The remaining pits and fissures will be sealed with the same material used for filling the cavity.
7. Condition the cavity and occlusal surface. Use a drop of dentin conditioner on a cotton wool pellet and rub both the cavity and the occlusal surfaces for 0 to 5 seconds. The conditioned surfaces should then be washed several times with wet cotton wool pellets. The surfaces are then dried with dry pellets. Rationale : Conditioning increases the bond strength of glass ionomers.
8. Mix glass ionomer according to manufacturer’s instructions. Do not alter the powder liquid ratio.
9. Insert mixed glass ionomer into the cavity and overfill slightly. The mixed material is inserted using the flat end of the applier, and plugged into corners of the cavity with the smooth side of an excavator or with a ball burnisher. Avoid the inclusion of air bubbles. The material also is placed over pits and fissures in small amounts.
10. Press coated gloved finger on top of the entire occlusal surface and apply slight pressure. Petroleum jelly (Vaseline) is used to coat the gloved finger to prevent the glass ionomer from sticking to the glove. Place the finger on top of the mixture, apply slight pressure for a few seconds, and remove the finger. Rationale : The finger pressure should push the glass ionomer into the deeper parts of the pits and fissures. Any excess material will overflow the occlusal surface and can be removed easily. A smooth restoration surface will result and reduce the need for carving.
11. Check the bite : Place articulating paper over the filling / sealant and ask the patient to close. The petroleum jelly (Vaseline) left on the surface will prevent saliva contact with the filling / sealant while the bite is checked.
12. Remove excess material with the carver. Usually only small corrections are required.
13. Recheck the bite and adjust the height of the restoration until comfortable.
14. Cover filling / sealant with petroleum jelly(Vaseline) once again or apply varnish.
15. Instruct the patient not to eat for at least one hour.
For restoring proximal cavities, a plastic strip and wedges are used to produce a correct contour to the filling.
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