Evolution of the ART approach: highlights and achievements

ABSTRACT Atraumatic Restorative Treatment (ART) was initiated in the mid-eighties in Tanzania in response to an inappropriately functioning community oral health programme that was based on western health care models and western technology. The approach has evolved to its present standing as an effective minimal intervention approach mainly because the originators anticipated the great potential of ART to alleviate inequality in oral health care, and because they recognised the need to carry out research to investigate its effectiveness and applicability. Twenty-five years later, ART was accepted by the World Health Organisation (1994) and the FDI World Dental Federation (2002). It is included in textbooks on cariology, restorative dentistry and minimal intervention dentistry. It is being systematically introduced into public oral health service systems in a number of low- and middle income countries. Private practitioners use it. Many publications related to aspects of ART have been published and many more will follow. To achieve quality results with ART one has to attend well-conducted and sufficiently long training courses, preferably in combination with other caries preventive strategies. ART should, therefore, not be considered in isolation and must be part of an evidence-based approach to oral health with a strong foundation based on prevention.


HISTORY OF EVOLUTION OF THE ART APPROACH
Atraumatic Restorative Treatment (ART) is a minimally invasive approach to both prevent dental carious lesions and stop its further progression. It consists of two components: sealing of carious-prone pits and fissures (ART sealants) and restoration of cavitated dentin lesions with sealant-restorations (ART restorations) 5 . The placement of an ART sealant involves the application of a high-viscosity glassunder finger pressure. An ART restoration involves the removal of soft, completely demineralised carious tooth tissue, using hand instruments. This is followed by restoration of the cavity with an adhesive dental material that simultaneously seals any remaining pits adhesive material predominantly used to restore cleaned cavities produced with hand instruments is a high-viscosity glass-ionomer. Restorations that have used rotary instruments for opening the cavity and hand instruments for cleaning the cavity are not considered ART restorations 7 . differ from conventional restorations 16 .
ART was initially developed in response to teeth in people of all ages in underserved communities where resources such as electricity, piped water, conventional dental equipment and So, what could be done? Necessity being 'the mother of invention', a small investigation was undertaken as to the kind of instruments that were available countrywide in dental clinics in Tanzania. It appeared that hand instruments were available, that most of the dental equipment was non-functional and that zinc-phosphate Consequently, the management of cavitated dentin lesions was based on the use of hand instruments and available restorative material.
In practice such an approach was not found to cause any insurmountable problems, since in many cases the cavity opening was large enough for removal of its soft content; there was no need to use a powerful drill to achieve this. Present, fracture in tooth 5 Present, overextention of approximal margin of 0.5mm or more* 6 Not present, most or all of restoration missing 7 Not present, other restorative treatment performed 8 Not present, tooth is not present 9 Unable to diagnose C Dentine carious lesion present Restorative Treatment (ART) was adopted: "Atraumatic" not only because of its low level of pain or discomfort, but also because of its minimal destruction of tooth tissue.

HIGHLIGHTS: RESEARCH AGENDA FOR ART
The  The General Assembly adopted ART as a minimal intervention approach.

CONCLUDING REMARKS
ART is sometimes criticized because it is seen as being merely a restorative treatment performed by dentists. What can restorative care and dentists do to improve oral health "the funny thing is that money doesn't seem to matter. They all pay for a restoration which is more expensive than an extraction. What matters for them", she said, "is the fact that teeth now can be restored and that it is done very friendly and pain free".
I was profoundly moved by this dentist's statement, remembering the humble beginnings of ART in that country some 25 years ago. Since the birth of ART, the approach has traveled the world. It has boosted the job satisfaction of many dentists and eliminated the suffering of many people. It was also instrumental in showing that by combining effective prevention with a approach it was possible to give hope to improving oral health for the many billions who do not have access to oral care. The fact that the ART team realized the need to engage in proper research from the very start has paid dividends and will continue to do for many years to come.