ART integration in oral health care systems in Latin American countries as perceived by directors of oral health

ABSTRACT The aim of this study was to carry out a situation analysis of: a) prevalence of ART training courses; b) integration of ART into the oral healthcare systems and; c) strengths and weaknesses of ART integration, in Latin American countries. Materials and Methods: A structured questionnaire, consisting of 18 questions, was emailed to directors of national or regional oral health departments of all Latin American countries and the USA. For two countries that had not responded after 4 weeks, the questionnaire was sent to the Dean of each local Dental School. The questions were related to ART training courses, integration of ART in the dental curriculum and the oral healthcare system, barriers to ART implementation in the public health system and recommendations for ART implementation in the services. Factor analysis was used to construct one factor in the barrier-related question. Means and percentages were calculated. Results: The response rate, covering 55% of all Latin American countries, was 76%. An ART training course had been given in all Latin American countries that responded, with more than 2 having been conducted in 64.7% of the respondent countries. ART was implemented in public oral health services in 94.7 % of the countries, according to the respondents. In 15.8% of the countries, ART was applied throughout the country and in 68.4%, in some areas or regions of a country. ART had been used for more, or less, than three years in 42.1% and 47.4% of the countries, respectively. evaluation and monitoring activities to determine the effectiveness of ART restorations and ART sealants had been carried out in 42.1% of the countries, while evaluation training courses had taken place in only 3 countries (15.8%). Respondents perceived the “increase in the number of treated patients” as the major benefit of ART implementation in public oral health services. The major perceived barrier factors to ART implementation were “operator opinion” and “high patient load”, followed by “lack in supplies of materials and instruments and operators” and “lack of ART training”. Respondents recommended that the number of ART courses should be increased. Conclusions: The introduction of ART into the public oral health systems in Latin American countries has taken place but is still in its infancy. More ART training courses need to be organized if the approach is to be adopted in oral health service systems in these countries.


INTRODUCTION
In many developing countries, access to and provision of oral health care is limited 12 .
Characteristically, the levels of untreated cavitated lesions are high. As the option of saving a painful tooth by placing a restoration is often not considered, because of a lack of functional dental equipment and materials, and because of the acceptance by patients that toothache can be alleviated only through extraction of a badly decayed tooth, toothache is usually treated by extraction 5 . This situation has arisen as a result of the unconditioned acceptance by governments and professionals in low-and middle-income countries of inappropriate oral healthcare models.
These are based on rotary-driven equipment and, although this type of health care has a place in developing countries, their use is more suited to high-income countries having the required infra-structure. In order to improve the situation in developing countries, their authorities need to identify oral care models that suit their health conditions, means and healthcare infra-structure. Makoni, et al. 6 (1997) showed that ART could be applied in 84% of dentine cavities in an adolescent population with a caries prevalence of 41% and a mean DMFT score of 1.1. The longevity of single-surface ART restorations in primary and permanent tooth has been reported to be good 8 .
Mickenautsch, Yengopal and Banerjee 8 (2009) found no difference in survival results, after six years, between single-surface ART restorations and comparable amalgam restorations in the permanent dentition.
The preventive component of ART, that is the sealing of caries-prone pits and fissures with a high-viscosity glass-ionomer, also showed good results, with an annual dentine lesion development of only 1% during the first three The evidence demonstrates that the ART approach produces quality sealants and quality restorations in single-surfaces both primary and permanent teeth. Thus the time has come to extend the structured introduction of ART into the national oral health policies of more low-and middle-income countries than those from which reports regarding its efficacy have been received: South Africa 7 , Tanzania 5 and Mexico 4 .

Science transfer
One of the most important, but at the same time very difficult, aspects of research is the transfer of results of studies into daily medical/ dental practice. The main difficulty is to get practitioners to accept, adopt and apply newly obtained evidence-based results. educating dental students for life-long learning in dental schools worldwide is only a recent development.
Personal experience shows that many dental schools have not adopted the problem-based learning concept. These continue to use the conventional teacher-student one-directional education system. It is not surprising that

MATERIALS AND METhODS
Questionnaire A structured questionnaire, consisting of 18 questions, was sent through the internet to directors of national or regional oral health departments of all Latin American countries and the USA between April and July 2009 ( Figure   1). A reminder was sent after four weeks. For the two countries that had not responded, the questionnaire was also sent to deans of dental schools.

Construction of variables
Factor analysis was performed for four items of the barrier question (Q15) to construct one factor, "operator opinion", which had a Cronbach's alpha of 0.62. All other barrier factors were single item statements.

Statistical analysis
Microsoft excel software was used for entering data onto the computer and checking for accuracy. The data were then transferred into an SAS program for analysis by a statistician. A question that was not answered was considered as "not being in agreement". Mean scores and percentages were calculated.

Disposition of subjects
From the total of 25 questionnaires sent, 19 were returned from 10 Latin American countries and 1 from the USA, covering 55% of all Latin American countries ( Table 1). The respondents were directors of national (42.1%) and regional Inclusion of ART in the community dentistry program of a dental school was affirmed by 31.6% of the respondents.

Implementation of ART in oral care systems
Almost all recipients (94.7%) responded that ART had been implemented in the nation's public oral health services; 15.8% stated that ART was used throughout their country, while 68.4% commented that it was used in only some areas or regions of their country. Only 2 stated that ART was used in private practices. With regard to the length of period that ART had been in used in these countries, 42.1% of the respondents indicated that it had been applied for more than three years, and 47.4% indicated that it had been applied for less than three years. With respect to identifying barrier factors inhibiting implementation of ART; "operator opinion" and "high patient load", followed by "lack in supplies of materials and instruments" and

Country
Frequency Percent "operators lack of ART training" were perceived by respondents in these countries to be the most important, as shown in Table 3.

DISCUSSION
The purpose of the present study was to investigate aspects of the integration of the ART approach into oral health care in Latin America.
The response rate was 76%, which implies that

Recommendations
In order to facilitate the integration of ART