The implementation and preliminary evaluation of an ART strategy in Mexico - a country example

ABSTRACT The massive use of preventive measures in Mexico including fluoride toothpaste, a national program of salt fluoridation and education on prevention has resulted in a large decline in dental caries over the past two decades. There does however remain a largely unmet need for restorative treatment. This paper describes the steps leading up to the adoption of a strategy, as part of general health policy, to use Atraumatic Restorative Treatment (ART) within the Mexican public health service as a means to address this. This included the development of training materials, the organization of training courses for existing dentists and the incorporation of ART into the undergraduate curriculum. Results: Six years after the introduction of ART in the year 2000, it was estimated that over 2 million ART procedures had been provided. As part of the planning cycle, an evaluation was undertaken in 2008 to determine amongst Mexican dentists what were the perceived problems when implementing the ART approach. Such research identified that the scarcity of appropriate dental materials and the lack of suitable instruments were the major problems. In addition, a preliminary evaluation of ART restorations and sealants placed as part of this National Oral Health Program was undertaken. The survival outcomes after one year compared favorably with one other study conducted in Mexico but were somewhat lower than the results reported from a number of other countries. Conclusion: The ambitious and forward thinking policy for improving the oral health in Mexico is now showing dividends. One example is the ART strategy, which has been successful both in terms of the number of ART procedures provided and generally in terms of clinical outcomes.


INTRODUCTION
Mexico has a high prevalence of oral diseases with tooth decay affecting 61% of children over 6 years old 11 . Oral problems constitute the fifth most common reason for visits to the country's health services 16 . In terms of preventive programs for oral health, the Mexican Congress, as part of its 1989-1994 National Health Plan, in 1973 6 . In 1991, Mexico became the seventh country in the world to adopt salt fluoridation to prevent dental caries 3  The concept was to implement a plan for the introduction of the ART approach in public clinics in 19 states selected for their degree of marginalization and lack of access to care 11 . A number of barriers were however encountered.
First, there was opposition to this approach by the dental association whose concerns included: a fear that caries would be left behind under ART restorations, that this in turn would lead to an irreversible pulpitis, and concerns about the reliability of the restorative material to be used. Other problems that emerged concerned the sourcing of suitable instruments and dental materials, especially high-strength glass ionomer, the availability of information material in Spanish on the ART approach and certain operational problems.
To resolve the latter problem a training In parallel with the activities to train existing dentists about the ART approach, there have also been efforts to train dental students with the aim of improving their attitude to ART as an alternative treatment for carious lesions. This will help the newly trained dental graduate, during their obligatory (six months to one year) working in social service mainly in municipalities with a lower index of human development. Similarly, the Mexican dental associations of the country have also been invited to join this strategy.

The attitudes of Mexican dentists to Atraumatic Restorative Treatment
In order to understand the attitude and views of Mexican dentists concerning the perceived major problems when implementing the ART approach in their practice and to determine where they considered such an approach could be best applied, a survey of 197 dentists was undertaken in 2008 in the states of Chiapas, Michoacan and Sinaloa. This survey found that the major problem for the implementation of ART, perceived by 45 % of the respondents, was the scarcity or unavailability of appropriate dental materials and the lack of suitable instruments; those that were available being of poor quality ( Figure 1). It was also noted that the reason that dentists had joined ART training courses was not only to receive information on how to undertake ART correctly but also to facilitate access to appropriate materials and instruments.
This survey also identified that just over 55% of the dentists surveyed strictly followed the correct ART approach using hand instruments alone, while the remaining dentists used either a high-or low-speed handpiece either alone or to compliment the use of hand instruments when preparing a cavity for an "ART" restoration. The

RESULTS
Of the 304 children who received ART treatment at baseline only 243 children were available at the one-year follow-up representing 80% of the original sample. In these children, 410 ART restorations were available for evaluation, 314 in primary teeth and 96 in permanent teeth.
A total of 390 ART sealants were also evaluated, 182 in primary and 208 in permanent teeth.
The survival of ART restorations and those restorations associated with caries at the oneyear evaluation for both primary and permanent teeth is given in Table 1. For this preliminary analysis the association between restoration failure and the finding of caries was not analyzed since this will be part of a subsequent reevaluation.
The survival of ART sealants at the one-year evaluation and caries associated with partretained and totally lost sealants is given in Table 2. Since the number of previously sealed teeth with caries was very low, further statistical analysis was unwarranted. 0 -No caries 1 -Caries associated with ART restoration 2 -Caries associated with ART sealant and with loss of sealant extension to ART restoration 3 -Caries on same tooth surface but not associated with ART restoration or ART sealant extension. 4 -Caries on tooth surface not associated with ART restoration or ART sealant 9 -Impossible to diagnose. The ART strategy has also been progressively scaled up as more and more existing dentists are trained in the approach and as newly qualified dentists join the workforce having been trained during their university studies.  Here, the photographs which were taken will be very useful in the future to identify whether this could have been the case but also as a teaching