Two decades of ART: improving on success through further research

ABSTRACT Since the introduction of the Atraumatic Restorative Treatment (ART) approach over twenty years ago, more than 190 research publications have appeared. The last research agenda defining research priorities for ART was published in 1999. The objective of the present work was to review existing research in the context of future research priorities for ART. Material and Methods: An internet survey was conducted amongst those who had published on ART or were known to be working on the ART approach, to solicit their views as to areas of future ART research. Three broad categories were defined, namely: 1. Basic and laboratory research; 2. Clinical research, and, 3. Community, Public Health, Health Services Research. Results: A 31% response rate was achieved. The study identified a number of new areas of research as well as areas where additional research is required. These are expressed as recommendations for future ART research. Conclusions: The ART approach is based on a robust, reliable and ever-growing evidence base concerning its clinical applications which indicates that it is a reliable and quality treatment approach. In common with all other oral health care procedures, targeted applied research is required to improve the oral health care offered.


INTRODUCTION
The famous quotation of Albert einstein that "If we knew what it was we were doing, it would not be called research, would it?" 25 holds as true for nuclear physics as it does to oral health and dentistry. In spite of the explosion of dental research over recent decades, the sad fact is that the everyday practice of dentistry has not made the quantum leap to enable effective and affordable oral health care to be brought to the vast majority of the over 6.8 billion people that now inhabit our planet.
Since the mid-1980's, when Frencken  A reasonable deadline was also given for replies.
Of the 76 persons who were sent an e-mail, the addresses used were found to be incorrect in 29 cases since the e-mail was returned by the internet service provider. In such cases the internet Google ® search engine was used with the author's name to try to identify a new contact address. eventually, this resulted in a total of 66 e-mails being successfully sent. One week after the given deadline a total of 21 responses had been received representing a 31% response rate.
The responses from this internet survey were compiled for a presentation given during While it is not the intention to routinely leave significant amounts of infected dentine when placing an ART restoration, sometimes this is the case to avoid a pulpal exposure (see later).
In such cases little is known about the effects of this on the dentine/pulp complex. Traditionally The objective of instrumentation with handinstruments, as used in the ART approach, is to remove the soft, heavily infected and unremineralisable "infected dentine" leaving behind the harder, minimally infected and remineralisable "affected dentine", thereby conserving sound tooth structure. Studies by Palma-Dibbs, et al. 53

Research on cavity size, shape and location
In order to achieve the most reliable results from the ART approach, careful selection of cases is essential. Here, factors such as cavity size, its shape and location might play an important role in predicting restoration survival. There are many parallels between the slow uptake of the use of sealants by dentists and the routine use of Atraumatic Restorative Treatment.

Research on the teaching of ART in dental schools
A common observation amongst respondents to the internet survey was that many dental schools were slow to adopt and practice concepts In preparation for the ART symposium during the 3 rd Latin American Regional Meeting of the IADR, in Venezuela (2009), this issue was investigated with respect to Brazilian dental schools 50 . This survey suggests that ART is taught in many of the dental schools in Brazil which is very encouraging. However these findings should not be considered to be the norm worldwide, since the ART approach continues to have a very active following in Brazil, which is not the case for many other countries.
It has been said that it is "easier to move a graveyard that to change a dental curriculum" 57

CONCLUSIONS
Since its conception, the ART approach has consistently been the subject of research in order to place the approach within a sound evidence base for its application to improve oral health.
As a result of this, the approach has evolved and improved as more was known about its strengths and weaknesses. There is now a robust, reliable and ever-growing evidence base concerning the clinical applications of the ART approach.
This however should not lead to complacency amongst the research community, since the current exercise seeking opinions about future ART research has identified several further topics for research. Some of these should be considered as "nice to know" rather than "need to know", since research outcomes are unlikely to make significant changes to the way that the ART approach is applied on a day-to-day basis.
Other areas are perhaps more important, for instance to identify the barriers that prevent the utilisation of ART and other Minimal Intervention approaches in routine dental practice and public oral health systems. By identifying such barriers action can be taken to reduce or remove them.
Such research will need to call on expertise outside the dental research field and involve sociologists, health economists and others to ensure that quality research is achieved.
It is hoped that the definition of a new research agenda, as detailed in this publication, will stimulate researchers in academia, public health administrators and industry to invest time and effort in this essential area of health care. It is also hoped that funding agencies will recognise the need to wholeheartedly support these activities with the objective of improving oral health, not only locally within countries, but globally.
ART has been a remarkable success story in the history of dentistry and oral health and the authors have a firm conviction that it will be possible to improve on this success through further research. In this respect, it is only fitting to conclude by quoting the words of one of the respondents to our internet survey, who wrote: "Your request for input from the clinical and research communities verifies selfless giving and collective problem solving to address needs of the underserved. I think that's what ART has been from the inception." Such a statement makes all our efforts worthwhile.

ACKNOWLEDgEMENTS
The development and evolution of ART over the past two decades would not have taken place if it hadn't been for the dedicated researchers who worked to build the evidence base for the approach. These researchers are far too numerous to list individually but this paper goes someway to acknowledge them and their work.
A special thanks must be given to all those who