Methods for carious dentine lesion management

Atraumatic restorative treatment

What it is and when to use it
ART involves using hand instruments to access carious lesions through enamel and to remove a selected amount of demineralised dental tissues. This is also known as a minimally invasive treatment.

How it works and clinical effectiveness
ART restorations with HVGIC have shown high success in long-term follow-up studies for single surfaces, in the primary and permanent dentitions, with meta-analyses showing weighted mean annual failure percentages of 5% in primary molars over the first three years, and 4.1% over the first five years in permanent posterior teeth.29 However, there are not enough studies on multi-surface restorations in the permanent dentition to recommend it as a long-term strategy yet. A recent systematic review reported no significant differences in survival percentages between ART and traditionally produced multiple-surface restorations in primary molars,72,73 and for single-surface restorations in primary molars and posterior permanent teeth.73 Large-sized multi-surface ART/HVGIC restorations in primary molars were less successful because of poor restorative material performance rather than the caries removal technique. However, ART may be a good short-term strategy for large multi-surface cavities or for stabilising the dentitions before other restorative interventions.

Non-AGP use
ART involves no rotary, aerosol-producing instruments during opening of the cavity and selective removal of the carious tissue. ART's success is determined not only by the shape and the sharpness of the hand instruments, but also the technique used as well as the knowledge of the affected dental tissues and experience of the dental practitioner.
In some deeper lesions in permanent teeth, stepwise carious tissue removal may have been the treatment of choice but involves a second high-speed air rotor step to remove the restoration. Therefore, following selective carious tissue removal, a restoration designed to last in the long term should be placed. The restoration seal should be checked and maintained as necessary on a regular basis.

Chemo-mechanical methods for carious tissue removal
Currently, there are sodium hypochlorite-based and enzyme-based CMCR agents in the market. A recent systematic review found CMCR time-consuming, but effective, for caries removal.74 The manufacturer's recommendations are that the caries removal agents are washed out, but could well be removed with spoon instruments and cleaned with wet cotton pellets.