|Year : 2014 | Volume
| Issue : 2 | Page : 71-75
Atraumatic restorative treatment for dental caries among pregnant women attending primary health centres: A small scale demonstration
Ramya Shenoy1, Animesh Jain2, M Kundabala3
1 Department of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India
2 Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal University, Karnataka, India
3 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India
|Date of Web Publication||15-Oct-2014|
Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal University, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: ART consists of a simplified, low-cost technique that uses only hand instruments in the removal of carious tissues to reduce contamination and viability of microorganisms. This technique requires immediate restoration of the cavity with adhesive restorative material, namely glass ionomer. Since ART approach causes lesser anxiety than the traditional restorative procedure, it may be a very useful tool for providing dental treatment to pregnant women. Objective: The present study was carried out to assess the pregnant women's response to undergo ART in Primary Health Centre set up and clinical evaluation of restoration at 6 month interval. Methods: Pregnant women visiting Primary health centres (PHCs) for prenatal check- up were examined. Those having cavities were restored using ART after taking informed consent. These were followed up telephonically 24 hours later and examined at the end of six months. Results: Of the 308 pregnant women examined, fifty teeth of forty five subjects (83%) were restored using ART. Out of that 45 (90%) were one surface restoration and five (10%) two surface restorations. None of the subjects felt pain during the procedure, 24 hours later or at the end of six months. All the subjects were satisfied with the treatment. All one surface fillings were intact and one out of five, two-surface filling was broken which was replaced with new restoration. Conclusion: This study demonstrates that the patients were satisfied with the ART which can be undertaken at lower cost. Together with preventive and promotional activities, oral health status of pregnant women who visit PHCs can be improved.
Clinical Relevance to Interdisciplinary Dentistry
- Being based on the contemporary philosophy of minimum intervention and maximum preservation of the tooth structure, atraumatic restorative treatment (ART) has been considered a feasible treatment option for moderate to deep carious lesions and can be applied to the entire population.
- As ART approach causes lesser anxiety than the traditional restorative procedure using dental rotary instruments, it can be used among target groups like children and pregnant women to treat dental caries.
- This article is an attempt at demonstrating the effectiveness of ART in pregnant women attending primary health centres. This could be utilized for preventive care in low resource and low-cost settings
Keywords: Atraumatic restorative treatment, dental caries, pregnant women, primary health centres
|How to cite this article:|
Shenoy R, Jain A, Kundabala M. Atraumatic restorative treatment for dental caries among pregnant women attending primary health centres: A small scale demonstration. J Interdiscip Dentistry 2014;4:71-5
|How to cite this URL:|
Shenoy R, Jain A, Kundabala M. Atraumatic restorative treatment for dental caries among pregnant women attending primary health centres: A small scale demonstration. J Interdiscip Dentistry [serial online] 2014 [cited 2022 Jan 28];4:71-5. Available from: https://www.jidonline.com/text.asp?2014/4/2/71/142937
| Introduction|| |
The health care system in India is a mix of public and private sector with the nongovernmental organizations playing small yet important role. The public health system in India is primarily under the purview of State Governments, with the Central Government providing broad policy guidelines, technical assistance, and additional resources. The rural health system in India is well structured. A sub-centre facility is the most peripheral health service delivery point in the health care infrastructure. A primary health centre (PHC), the next level, caters to a population of 30,000 and oversees 6-8 sub-centres. A PHC is staffed by one or two physicians, a lady health visitor and one or more auxiliary nurse midwives. For every 3-4 PHCs there is a provision for community health centres (CHCs), the total of which is 2953 nationwide.  PHCs in India do not have dental clinics. Only a few CHCs have dental clinics; unfortunately, these are not well equipped in accordance with the required standards and specifications for the practice of conventional dentistry for caries control. 
With the goal of encouraging health promotion measures required for control and prevention of dental caries, the World Health Organization (WHO) had proposed the program of atraumatic restorative treatment (ART) for countries with economically underprivileged or marginalized communities. ,,, ART, as part of the basic package of oral care, is an important cornerstone for the development of global oral health and alleviating inequality in oral care. ,, In outreach situations in three Latin American countries, the ART approach has proved more cost-effective than conventional dental caries management. Consequently, WHO adopted ART in 1994, the WHO Africa Office included ART in its strategic oral health policy guidelines 1999-2008 and Pan American Health Organization recommended the use of ART to manage dental caries in Latin-American countries. 
Atraumatic restorative treatment has been considered a feasible treatment option, as it is based on the contemporary philosophy of minimum intervention and maximum preservation of the tooth and can be applied to the entire population. ART consists of a simplified, low-cost technique that uses only hand instruments in the removal of carious tissues to reduce contamination and viability of microorganisms.  It requires immediate restoration of the cavity with adhesive restorative material, namely glass ionomer which is modified material to suit the requirement. ,,,, Using ART, dentists can provide restorative care in the dental clinic even if conventional equipment is unavailable or out-of-order, and in outreach situations. ART does not rely on electricity and piped water systems which are required for conventional rotary restorative treatment procedures. ,, Among the reasons given for avoiding dental treatment, the most important were those related to the patient's comfort which is, use of local anaesthetic and the noisy drill and suction. The most relevant aspects of the ART approach is to change the patients' expressions from fearful to more relaxed. These experiences contributed to increase in confidence among operators. , Moreover, the ART approach causes less anxiety than the traditional restorative approach. ,,,,,
Pregnant women being one of the target groups for oral health care, utilization of oral health care services among them should be surveyed. Few reasons had been cited to prevent them from availing dental treatment, like fear and anxiety about the treatment.  Due to the "atraumatic" aspects, , the ART approach may be a very useful tool when treating pregnant women. However, there is still apprehension among dentists about its utility and acceptance among the people. There is also a lack of published research or trials where ART has been utilized in population setting in the sub-continent. Keeping this in mind the present study was carried out to assess the pregnant women's response to undergo ART in PHC set - up and clinical evaluation of restorations at 6 months interval. This paper describes our experience with ART with respect to its implementation and response from the participants.
| Materials and methods|| |
The present study is a part of an on-going study titled "effectiveness of the basic package of oral care in pregnant women in PHCs on the incidence of early childhood caries in their children - A cluster randomized controlled trial." In this trial, the PHCs are the unit of randomization. Lottery method is used to randomly allocate PHCs into intervention group and control group. Along with the routine oral health examination, the basic package of oral care is provided to the study subjects in the intervention group. They are also provided with the fluoridated toothpastes throughout the study period. However, the study subjects in the control group underwent routine oral health check-up and are referred to the dental clinic in a dental college if required.
This study was approved by the Institutional Ethics Committee of our institution. Pregnant women having carious lesions involving the dentine, with the lesion being accessible to hand instruments were included in this study. Women with oral tissue swelling or oral fistula, exposure of the dental pulp, chronic symptomatic teeth, obvious carious cavity inaccessible to hand instruments were excluded. Written informed consent was taken from the participants before enrolling them into the trial. ART was given to the participants enrolled. The instrument used were mouth mirror, explorer, pair of tweezers, spoon excavator in three sizes (small (Ash 153-154), medium (Ash 131-132) large (Ash 127-128)), dental hatchet, applier/carver. Mixing-pad, spatula, GC Gold Label glass ionomer-high strength posterior restorative, cotton wool rolls, cotton wool pellets, White Petroleum Jelly I.P., plastic strip and wedges. Carious lesion, if any, were excavated by a sharp excavator from an isolated carious tooth, glass ionomer cement was mixed as per manufacturers' instructions, and cavities were restored  [Table 1]. To restore the multiple surface cavities, along with above check list the Mylar strip between the teeth and a wedge was placed to support the strip under the contact point at the gum margin. Other steps were similar to one surface filling.
Once the treatment was given, information regarding presence or absence of associated with the ART procedure was collected through interview. After 24 h, participants were called telephonically to confirm whether pain or discomfort associated with restoration. The clinical evaluation and the overall satisfaction were assessed at the end of 6 months from treatment. Restoration was considered as failed if it was completely missing and/or fractured. In the present study, the entire procedure was carried out by a single public health dentist to avoid the clinician bias.
| Results|| |
A total of 308 pregnant women were enrolled into the trial. Of these, 54 (18%) women (35 in the intervention and 19 in the control group) had cavities in 65 teeth that could be restored using ART. However, nine of the eligible women did not undergo dental treatment due to lack of time, fear of the dentist and not interested. Characteristics of participants who underwent ART are listed in [Table 2]. Forty-five subjects (83%) with 50 teeth were restored using ART. Of these, 45 (90%) teeth were one surface filling and 5 (10%) two-surface filling. None of the subjects reported having felt pain during the procedure. After 24 h, participants were called telephonically to confirm whether pain or discomfort associated with restoration. None of the participants had pain or discomfort in relation to ART. Clinical evaluation of the restoration was carried at 6 months. All the subjects were satisfied with the treatment. All one surface fillings were intact and one out of five two-surface fillings was broken which was replaced with new restoration [Figure 1].
|Figure 1: Flow chart showing sequence of events from initiation of atraumatic restorative treatment to six months evaluation|
Click here to view
| Discussion|| |
Utilization of health care services by pregnant women is not to the full extent for various reasons.  Dental health and treatment are generally more neglected, and consultation is done when the oral health condition has significantly worsened. Pregnant women need to avail dental care to prevent infection and also to have a good sense of oral hygiene.  Women have a larger role of imparting the importance of oral health and keeping up the good health status of the family and children in particular. As stated earlier, the ART approach may be a very useful tool when treating pregnant women mainly because of its "atraumatic" aspect. Studies are assessing pain or discomfort related to ART report that this approach is more patient-friendly when compared to other restorative treatments. ,,, However, they differ concerning the methodology used to assess the level of pain. We could find only one published study on pain and ART in the adult population. Hence, in the present study we wanted to evaluate the prevalence of pain due to ART technique especially in pregnant women. In the present study, none of the subjects felt pain during the treatment. All of them were satisfied with the treatment. This result is in accordance with a study carried out in South Africa.  About 19.3% of the children in the ART approach group reported sensibility during the procedure in the study carried out by Rahimtoola et al.  In the present study nine subjects (16.6%) did not agree to undergo ART; one of the commonest and most important reasons for their refusal to participate was fear of discomfort. Nevertheless, a good number of participants agreed to undergo ART.
The acceptance of the ART by the pregnant women and no incidence of pain in the present study can be attributed to proper case selection, restorative material used, proper technique used and experience of public health dentist.
However, a limitation of the study was that only presence or absence of pain was noted, and the intensity of pain was not measured since there was no incidence of pain. The present study was a small scale demonstration of implementation of ART; it can be carried out in a larger scale with a longer follow-up.
| Conclusion|| |
In this study majority of the patients were satisfied with the ART approach and dental care can be undertaken at lower cost through ART. Together with preventive and promotional activities, oral health can be adequately provided at PHCs.
| Acknowledgements|| |
This study was funded by Vision Group of Science and Technology, Government of Karnataka under the Category - "Award of Seed Money to Young Scientist for Research" - GRD-280. The authors would like to thank all the participants of this study. They also express their gratitude toward Dr. Dilip G. Naik, Dean of MCODS, Mangalore, Karnataka, India for his kind support, guidance and encouragement.
| References|| |
|1.||World Health Organization, South-East Asia Region. Basic Indicators: Health Situation in India. New Delhi:World Health Organization; 2004. |
|2.||Sumit K, Kumar S, Saran A, Dias FS. Oral health care delivery systems in India: An overview. Int J Basic Appl Med Sci 2013;3:171-8. |
|3.||Frencken J, Phantumvanit P, Pilot T, Songpaisan Y, van Amerongen E. Manual for the Atraumatic Restorative Treatment Approach to Control Dental Caries. 3 rd ed. Groningen, The Netherlands: WHO Collaborating Centre for Oral Health Services Research, University of Groningen; 1997. |
|4.||Frencken JE, Leal SC, Navarro MF. Twenty-five-year atraumatic restorative treatment (ART) approach: A comprehensive overview. Clin Oral Investig 2012;16:1337-46. |
|5.||Kikwilu EN, Frencken J, Mulder J. Impact of atraumatic restorative treatment (ART) on the treatment profile in pilot government dental clinics in Tanzania. BMC Oral Health 2009;9:14. |
|6.||Holmgren CJ, Figueredo MC. Two decades of ART: Improving on success through further research. J Appl Oral Sci 2009;17 Suppl: 122-33. |
|7.||Frencken JE, Leal SC. The correct use of the ART approach. J Appl Oral Sci 2010;18:1-4. |
|8.||Frencken JE, Holmgren CJ. How effective is ART in the management of dental caries? Community Dent Oral Epidemiol 1999;27:423-30. |
|9.||Frencken JE. Evolution of the ART approach: Highlights and achievements. J Appl Oral Sci 2009;17 Suppl: 78-83. |
|10.||Smales RJ, Yip HK. The atraumatic restorative treatment (ART) approach for the management of dental caries. Quintessence Int 2002;33:427-32. |
|11.||Carvalho TS, Ribeiro TR, Bönecker M, Pinheiro EC, Colares V. The atraumatic restorative treatment approach: An "atraumatic" alternative. Med Oral Patol Oral Cir Bucal 2009;14:e668-73. |
|12.||Schriks MC, van Amerongen WE. Atraumatic perspectives of ART: Psychological and physiological aspects of treatment with and without rotary instruments. Community Dent Oral Epidemiol 2003;31:15-20. |
|13.||Rahimtoola S, van Amerongen E, Maher R, Groen H. Pain related to different ways of minimal intervention in the treatment of small caries lesions. ASDC J Dent Child 2000;67:123-7, 83. |
|14.||de Menezes Abreu DM, Leal SC, Frencken JE. Self-report of pain in children treated according to the atraumatic restorative treatment and the conventional restorative treatment - A pilot study. J Clin Pediatr Dent 2009;34:151-5. |
|15.||Topaloglu-Ak A, Eden E, Frencken JE. Perceived dental anxiety among schoolchildren treated through three caries removal approaches. J Appl Oral Sci 2007;15:235-40. |
|16.||Mickenautsch S, Frencken JE, van't HM. Atraumatic restorative treatment and dental anxiety in outpatients attending public oral health clinics in South Africa. J Public Health Dent 2007;67:179-84. |
|17.||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;119:163-8. |
|18.||Le M, Riedy C, Weinstein P, Milgrom P. Barriers to utilization of dental services during pregnancy: A qualitative analysis. J Dent Child (Chic) 2009;76:46-52. |
[Table 1], [Table 2]