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Atraumatic Restorative Treatment (ART) in Pediatric Dentistry Residency

Programs: A Survey of Program Directors

Article  in  Pediatric dentistry · December 2013

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PEDIATRIC DENTISTRY V 35 / NO 7 NOV / DEC 13

Clinical Article CROSS SECTIONAL

Atraumatic Restorative Treatment (ART) in Pediatric Dentistry Residency Programs:

A Survey of Program Directors
Elham Kateeb, BDS, MPH, PhD1 • John Warren, DDS, MS2 • Peter Damiano, DDS, MPH3 • Elizabeth Momany, PhD4 • Michael Kanellis, DDS, MS5 •
Karin Weber-Gasparoni, DDS, MS, PhD6 • Tim Ansley, MS, PhD7

Abstract: Purpose: The purpose of this study was to investigate the extent of clinical training on atraumatic restorative treatment (ART) among
pediatric dentistry residency programs and assess program directors’ attitudes toward ART. Methods: All U.S. Pediatric Dentistry residency pro-
grams’ directors were asked to complete a web-based survey. Sixty-one of the 76 directors (80 percent) completed the survey, with no significant
response bias. Results: Eighty-nine percent of the responding programs provided clinical instruction on ART. Of these, 30 percent provided ART
training often/very often. ART was used mostly in single-surface cavities (43 percent) and as an interim treatment in primary teeth (57 percent).
Factors associated with ART clinical training included not placing amalgams in primary teeth (P<.03) and having directors with positive attitudes
toward ART (P<.001). Factors associated with directors’ positive attitudes included believing that child’s caries risk (P<.006), professional guide-
lines (P<.003), and patient insurance status (P<.04) were all important in selecting restorative treatment. Conclusions: Atraumatic restorative
therapy appears to be underused in pediatric dentistry residency programs in the United States. Residency directors’ attitudes were highly pre-
dictive of the amount of clinical training provided, suggesting that directors need to be better informed about the use of ART. (Pediatr Dent
2013;35:500-5) Received February 15, 2012 | Last Revision January 28, 2013 | Accepted January 29, 2013

KEYWORDS: DENTAL ATRAUMATIC RESTORATIVE TREATMENT, PEDIATRIC DENTISTRY/EDUCATION, QUESTIONNAIRES

Access to oral care is still problematic for certain populations in Although the ART approach was initially developed to provide
the United States. Among the factors that limit access are the preventive and restorative care to people in low-income countries,
limited availability of services and inability to pay for services. To the use of ART is no longer restricted to underprivileged nations.
address such problems, strategies to make services more efficient, The World Health Organization and International Dental Federa-
affordable, and less traumatic have been suggested. Atraumatic tion recognize ART as part of the basic package of oral care for
restorative treatment (ART) was proposed as one solution to all communities around the world.4,5 They view ART as an innova-
achieve those goals. ART was developed in the 1980s as an afford- tive highly effective approach suitable for populations at all levels
able, patient-friendly caries management procedure that does of economic development. They also believe that ART fits modern
not need extensive operator training or special skills. concepts of preventive and restorative oral care, with a focus on
A recent meta-analysis in 2010 showed that survival of ART prevention and minimally invasive restorative care.
restorations was 93 percent over two years in single-surface re- Few studies reported the use of ART in economically devel-
storations and 62 percent in multiple surface restorations in pri- oped countries; in England and Scotland, only 10 percent of
mary teeth.1 In permanent teeth, survival was 80 percent over general dentists had adopted ART to treat children.6 In the Nether-
five years in single-surface restorations and 86 percent over one lands, ART was used by 26 percent of general dentists.7 The
year in multiple-surface restorations.1 Another systematic review authors of the previous studies thought those results might be
in 2011 showed that, when compared with amalgam, there was due to some dentists viewing ART as inferior care 6 or the lack
no significant difference between the two restorations after 12 of economic incentives, as many reimbursement systems do not
and 24 months in primary teeth.2 In permanent teeth, ART re- recognize Minimally Invasive Dentistry (MID) procedures such
storations survived better than amalgam for up to 6.3 years, but as ART.8
survival was site-dependent; occlusal restorations had a higher The use of ART in the United States is not as well-established
survival rate than occluso-proximal restorations.2 Those survival or well-studied. In the 2011 revision of its policy statements, the
rates qualified ART to meet the American Dental Association American Academy of Pediatric Dentistry (AAPD) considered
(ADA) specification for quality restorations, especially for single- ART to be a definitive treatment used with populations that have
surface restorations.3 little access to traditional dental care.9 At the same time, the AAPD
recognized another type of ART: interim therapeutic restora-
tions (ITRs), which are similar to ART in technique but differ in
1Dr. Elham is an assistant professor, Al Quds University School of Dental Medicine and therapeutic goals. Both scoop out dental caries using hand instru-
a research associate at the University of Iowa; Drs. 2Warren and 3Damiano are pro-
ments and place glass ionomer (GI) to restore the resultant cavity;
fessors, Department of Community and Preventive Dentistry; 4Dr. Momany is an asso- however, ITRs were recommended as an interim treatment prior
ciate research scientist, Public Policy Center; 5Dr. Kanellis is a professor and 6Dr. Weber- to definitive restoration of the teeth.9 At a public health level and
Gasparoni is an associate professor, Department of Pediatric Dentistry, and 7Dr. Ansley in its most recent initiative to prevent early childhood caries, the
is an associate professor, Department of Psychological and Quantitative Foundations, Indian Health Service promoted the use of ART to reduce the
all at the University of Iowa, Iowa City, Iowa. need for children having to go to the operating room to receive
Correspond with Dr. Elham Kateed at [email protected] dental treatment.10

500 ATRAUMATIC RESTORATIVE TRE ATMENT (ART)

 PEDIATRIC DENTISTRY V 35 / NO 7 NOV / DEC 13

While recent recommendations and policy statements have this study. In addition, the program director’s attitude toward
advocated the use of ITR and ART, knowledge and use of these ART (composite variable, described next) was used as an inter-
techniques may be lacking. For example, in a national sample that mediate variable (acted as both predictor and outcome variable).
represented 43 percent of pediatric dentists in 2001, 51 percent Figure 1 shows the conceptual framework of the variables in this
“cleaned caries by spoon and placed glass ionomer” when they study.
were asked about the most frequent caries management techni- The composite variable (the use of MID techniques) in-
ques they usually used with children younger than three years cluded 11 MID procedures that were agreed on during the cog-
old.11 In a similar study among general dentists, 44 percent of nitive analysis phase of questionnaire development. The scale
dentists often used ART as a restorative procedure to treat chil- was the sum of responses to the 11 questions, each measured on
dren; however, 38 percent of the same sample knew nothing a 5-point frequency scale (never=1, rarely=2, sometimes=3,
about ART, and 32 percent thought that further training on often=4, most often=5). The internal consistency of this scale was
ART was “not desirable.”12 measured by Cronbach’s alpha, which was 0.7, suggesting a high
Given the strong evidence of the great impact of dental educa- level of consistency. The scale was used as a predictor variable
tion and training on future dentists’ attitudes and behaviors,13-16 in this model and had a mean of 38 (SD±6) in the study sam-
the under use of ART may reflect that little attention is given to ple. For this scale, a respondent who scored “never” all the time
ART in dental education in general and in pediatric dentistry would have a total score of 11, and the respondent who scored
training programs in particular. However, very little is known “most often” all the time would have a total score of 55.
about ART-related training in U.S. dental education. The composite variable regarding program directors’ atti-
Therefore, the purposes of this study were to: (1) assess fac- tudes toward ART was used as an intermediate variable in this
tors related to the attitude of pediatric dentistry residency program model. The agreement or disagreement of program directors
directors toward atraumatic restorative treatment; and (2) assess with 10 statements about ART was measured on a 5-point Likert
factors related to the level of clinical training on ART in pediatric scale. The scale summed the scores for each subquestion, ranging
dentistry residency programs in the United States. from 1=strongly disagree to 5=strongly agree. Therefore, the most
negative attitude would be 10 and the most positive attitude
Methods would score 50 on this scale. The scale had a Cronbach’s alpha
The Institutional Review Board of the University of Iowa, Iowa coefficient score of 0.8, and the mean for the study sample was
City, Iowa, approved all aspects of this study. This was a cross- 37 (±7).
sectional study of pediatric dentistry residency program directors The level of clinical training provided on ART was mea-
in the United States using a pretested web-based questionnaire sured by the question: “How often do pediatric dentistry residents
with 51 items. The survey was pretested for content validity using use ART as a caries management technique for their patients?”
cognitive analysis (by consulting and pretesting the instrument Responses were measured on a 5-point frequency scale (never=0
with experts) by six faculty members from the Department of to very often=5). For this survey, ART was defined as “a pro-
Preventive and Community Dentistry, four faculty members from cedure based on removing carious tooth tissues using hand
the Department of Pediatric Dentistry, and one faculty member instruments alone and restoring the cavity with an adhesive re-
from the Department of Operative Dentistry at the University of storative material.”17
Iowa in the spring of 2010. Pilot testing for face validity was Statistical analysis. The statistical analysis was carried out
conducted by two pediatric dentistry senior residents and two using SPSS 18.0 software (SPSS Inc, Chicago, Ill., USA). 18 Bi-
dental public health senior residents. variate analyses were conducted to consider associations between
Program directors of all 76 pediatric dentistry residency pro- outcome variables (dependent variables) and each potential pre-
grams identified by the AAPD and accredited by the ADA as dictor variable (independent variables) and to develop the most
of May 2010 were invited to participate in this survey. Eligible parsimonious multivariable models. Multiple linear regression,
programs included hospital-based, dental school-based, and com- stepwise and backward, was used for “the level of clinical training
bined programs.
An invitation letter, signed by the principal investi-
gator, research chairperson, and two members of the re-
search team, was mailed to all program directors in early
May 2010. After seven days, an e-mail, including a cover
letter that described confidentiality safeguards, the link
to the web survey, and a unique identification number,
was sent to all directors. Two reminder e-mails with the
web survey link and the unique identifier number were
sent again two and four weeks after the original e-mail to
those who did not submit the completed survey or did not
opt out.
The questionnaire was divided into five sections:
(1) program directors’ characteristics; (2) residency pro-
gram characteristics; (3) the characteristics of the patient
population served by the program; (4) the attitude of
program directors toward ART; and (5) the level and
format of clinical instruction on ART.
Besides the demographic characteristics of the pro-
gram and the program director, section two included
questions about the use of behavior management tech-
niques in the program (two questions) and the use of
different MID techniques in the program (11 questions).
Those questions were used as key independent variables in Figure 1. Conceptual model of the study.

ATRAUMATIC RESTORATIVE TRE ATMENT (ART) 501

PEDIATRIC DENTISTRY V 35 / NO 7 NOV / DEC 13

on ART” and the “attitude of program directors toward ART” in determining restorative options to be used with children and
outcome variables. Additionally, possible statistical interactions those who disagreed that “definitive restorations should be the
between the predictor variables were examined. All tests were treatment of choice regardless of other factors.” On the contrary,
assessed at a 0.05 level of statistical significance. programs that used amalgam in primary teeth more often were
associated with a negative attitude toward ART.
Results Level of clinical training provided on ART. Although 89
The overall response rate for this study was 80 percent, with 61 percent (n=45) of program directors stated that they provide
programs out of 76 responding. Respondent and nonrespondent clinical instruction on ART for their residents, only 30 percent
programs were compared in a descriptive way, according to vari- used this technique “very often” or “often” as a caries manage-
ables obtained from the AAPD programs’ profile including ment technique for their pediatric patients. Specifically, ART
number of students and faculty and level of stipends provided. was reported to be used more often in anterior primary teeth, in
No response bias was detected based on these comparisons. single-surface cavities, and as an interim treatment. Table 3 pre-
Program directors’ characteristics. Sixty-one percent of re- sents some of the types of ART used by those programs.
spondents were male. Eighty-seven percent had graduated from a In multiple linear regression, four predictor variables re-
U.S. dental training program, and 60 percent completed their mained significant in the final model (Table 4): (1) the attitude
training in hospital-based programs. Ninety percent of the pro- toward ART composite variable; (2) the use of MID composite
gram directors who responded to this survey were board certified,
and 49 percent had other post DMD/DDS training or degrees.
Study sample characteristics are provided in Table 1. Table 1. STUDY SAMPLE CHARACTERISTICS
When discussing restorative treatment options with their
residents, 99 percent of program directors cited children’s caries Program director Mean±(SD) Median Minimum Maximum
risk as “very important” or “important,” 77 percent cited parental characteristics
preference as “very important” or “important,” and only 38 per- Age (ys) 53±12 54 32 75
cent cited patient insurance status or source of payment as “very
No. of years spent in the following settings before becoming a program director
important” or “important.”
Approximately 97 percent of the sample reported that pro- Private practice 8±10 3 - 40
fessional guidelines were “very influential” or “influential” on their Academics (full-time 8±8 5 - 35
knowledge regarding different restorative options, 92 percent faculty)
cited continuing education, and 84 percent cited post-doctoral Public Health Service 1±3 - - 20
training as a “very influential” or “influential” source. Military dental corps 0.41±3.00 - - 20
Program characteristics. Thirty respondent programs were Percent of time per week spent in each of the following in the past 12 months
dental school-based, 30 were hospital-based, and one was based in
Research 9±11 5 - 60
a public health or community center. Fifty-two programs were
located in urban areas, with 39 programs located in inner cities. Administration 30±17 30 5 100
Seventy-nine percent of the programs used general anesthesia Direct patient care 21±19 20 - 95
“very often” or “often” with children three years old or younger, Teaching/student 41±21 40 - 100
and 52 percent used it “very often” or “often” with children older supervision
than three years.
Patient population served by the program characteristics.
A mean of 74 percent (±13 percent) of the patient population Table 2. RESULTS OF MULTIPLE LINEAR REGRESSION OF THE
served by respondent programs was at high caries risk, and 20 ATTITUDE OF PROGRAM DIRECTORS TOWARD
percent (±11 percent) was at low caries risk. Approximately 77
ATRAUMATIC RESTORATIVE TREATMENT COMPOSITE
percent (±20 percent) of respondent programs’ patients were
covered by Medicaid and other public insurance, 11 percent (±10 VARIABLE
percent) were covered by private insurance, and 10 percent Predictor variable Beta P-value
(±11 percent) had no insurance. Twenty-one percent (±13 percent) coefficient
of respondent programs treated children with intellectual and
developmental disabilities. Directors who think child’s caries risk is a very .32 .006
important factor when discussing different
Attitudes of program directors toward ART. For this sam- treatment options with their residents
ple of 61 program directors, the scores of the “attitudes of program
directors toward ART” scale ranged from 10 to 49. The scale Directors who strongly disagree with the state- .33 .003
distribution was skewed toward a more positive attitude, with only ment “definitive restorations should be the
treatment of choice, regardless of other factors”
four program directors scoring less than 27, and 22 directors
scored between 40 and 50 on the same scale. However, the Directors who think that patient insurance sta- .22 .04
results showed 38 directors scored between 10 and 40 on the tus is a very important factor when discussing
different treatment options with their residents
attitude scale, which indicates that most of the directors were
more neutral toward ART. Directors who think that professional guide- .35 .003
In the final regression model of the outcome variable “attitude lines and standards of care are very important
factors when discussing different treatment
toward ART,” five variables, shown in Table 2, were significant
options with their residents
and explained 45 percent of the variation of program directors’
Programs that place amalgam in primary teeth -.29 >.01
attitudes. The variables that were significant predictors for positive more often
attitudes toward ART included program directors who thought
a child’s caries risk, professional guidelines and standards of *R square =0.45; F=6.7, P>.01 (using the stepwise method and confirming the
care, and patient insurance status were very important factors results with forward and backward regression).

502 ATRAUMATIC RESTORATIVE TRE ATMENT (ART)

 PEDIATRIC DENTISTRY V 35 / NO 7 NOV / DEC 13

Table 3. RESULTS OF THE FREQUENCY OF USE OF DIFFERENT TYPES OF ATRAUMATIC RESTORATIVE

TREATMENT (ART) AMONG 54 PEDIATRIC RESIDENCY PROGRAMS (89% OF OUR SAMPLE) WHO
ANSWERED YES TO PROVIDING CLINICAL TRAINING ON ART
Types of ART used in pediatric dentistry Never Rarely Sometimes Often Very often Total
residency programs n (%) n (%) n (%) n (%) n (%) n (%)

ART in anterior primary teeth 0 (0) 3 (5) 15 (25) 17 (27) 18 (30) 53 (98)
ART in posterior primary teeth 1 (2) 12 (20) 25 (41) 8 (13) 6 (10) 52 (96)
ART in posterior permanent teeth 10 (16) 27 (44) 14 (24) 2 (3) 0 (0) 53 (98)
ART in single-surface cavities in primary teeth 1 (2) 5 (8) 24 (39) 13 (22) 10 (16) 53 (98)
ART in a single-surface cavities in permanent teeth 9 (15) 23 (38) 19 (31) 2 (3) 0 (0) 53 (98)
ART as an interim treatment in primary teeth 0 (0) 4 (7) 19 (31) 17 (28) 13 (21) 53 (98)
ART as an interim treatment in permanent teeth 6 (10) 11 (18) 25 (41) 6 (10) 4 (7) 52 (96)
ART as a definitive treatment in primary teeth 20 (12) 25 (15) 21 (13) 18 (11) 3 (2) 53 (98)
ART as a definitive treatment in permanent teeth 27 (44) 19 (31) 6 (10) 1 (2) 0 (0) 53 (98)

variable; (3) frequency of the use of general anesthesia with chil- with two recent U.S. studies in which the results showed more
dren three years old or younger; and (4) placing amalgam in positive attitudes toward MID in general and toward ART in
primary teeth more often. Those variables explained 50 percent particular among civilian, federal, and public health dentists.19-21
of the variation in the level of clinical training provided in those Professional guidelines were rated in our study and in differ-
programs. ent surveys of pediatric dentists as an important source of know-
Among the 12 percent who answered “no” to the question ledge about different treatment modalities.11,21 Despite the fact
“does your program provide clinical instruction on ART, as de- that the AAPD guidelines gave ART another name and endorsed
fined above,” five percent cited “residents should learn ideal re- it only as an interim restoration, the AAPD encourages the use of
storations first” as a reason for not including ART in their training ART with very young, uncooperative, and high caries-risk chil-
programs. Other reasons cited were: “no special ADA code exists dren.8 This may explain how professional guidelines predicted a
to reimburse ART restorations” (three percent); “ART is a sub- more positive attitude toward ART in our multivariable model.
optimum treatment” (three percent); and “insufficient scientific As in the present study, patients’ insurance status has been
evidence that supports the use of ART” (three percent). identified previously as an important factor in selecting a restora-
tive treatment option for children.11,12,21 However, in our study it
Discussion was identified also as a strong predictor for a positive attitude
The response rate for this study (80 percent) is considered to toward ART. In a 2001 survey of a national sample of pediatric
be high, suggesting that the findings may be generalized to all dentists, respondents indicated that certain restorative modalities
training programs. Moreover, no response bias was found between are more effective with Medicaid patients than others.11 Thus, the
respondent and nonrespondent programs, which further suggest fact that a program has most of its population covered by a parti-
that our sample was representative of all pediatric dentistry resi- cular insurance status may influence the attitude of the program
dency programs in the United States. The results of the “attitude directors toward certain procedures that may be more feasible
of program directors toward ART” scale appears to be in line with certain payment types.
The use of general anesthesia as a behavior management tech-
nique with children younger than three was a significant predictor
Table 4. RESULTS OF MULTIPLE LINEAR REGRESSION OF THE for the level of clinical training on ART provided in those pro-
VARIABLE CLINICAL TRAINING ON ATRAUMATIC grams. This could be explained by two reasons. First, programs
RESTORATIVE TREATMENT PROVIDED TO RESIDENTS that use GA more often with very young children seem to operate
IN PEDIATRIC DENTISTRY RESIDENCY PROGRAMS within a high caries-risk population, which, in turn encourages
Predictor variable Beta P-value
the use of ART. Or, second, programs may use ART as a caries
coefficient
stabilization technique until young children can be admitted to
the operating room.
Programs with directors who had more .346 .001 In addition, programs that placed amalgam restorations in
positive attitudes toward ART primary teeth more often also used ART less often as a caries man-
Programs that use minimally invasive tech- .283 .009 agement technique with children. This agrees with results from a
niques more often 2001 national survey, where 96 percent of pediatric dentists used
Programs that use general anesthesia as a .285 .006 definitive treatments such as amalgam and stainless steel crowns
behavioral management technique for chil- for all types of lesions, while only 30 percent used GI for the
dren three years old or younger more often same lesions.11
Programs that place amalgam in primary -.229 >.03 Finally, after controlling for other variables, attitude toward
teeth more often ART alone explained 35 percent of the level of clinical training
on ART. This was expected within the frame of the well-known
* R square=0.50; F=4.83, P<.03 (using the stepwise method and confirmed by influence of attitude on behavior and training provided to stud-
backward and forward regression). ents, as cited in other literature.22

ATRAUMATIC RESTORATIVE TRE ATMENT (ART) 503

PEDIATRIC DENTISTRY V 35 / NO 7 NOV / DEC 13

Our results suggest that, in spite of strong evidence that sup- 6. Given the underuse of ART, it appears that  American
ports ART’s effectiveness, this technique still faces some resistance Academy of Pediatric Dentistry guidelines need to be
among dental educators and practitioners, as evidenced by the tailored to better inform  pediatric dentistry residency
relatively small proportion (30 percent) that used ART often or program directors about ART.
very often. This resistance occurs mainly due to the lack of
knowledge about ART technique and the concept of minimal References
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Abstract of the Scientific Literature

A serial cross-sectional study of pediatric inpatient hospitalizations for non-traumatic dental conditions
The aim of this study was to examine trends of non-traumatic dental conditions (NTDCs)-related hospitalization in the United States
and identify the relationship between complex chronic condition (CCCs) and NTDC-related inpatient hospitalizations. Investigators anal-
yzed the data from U.S. Nationwide Inpatient Samples from 2000-2010 for children ages three to 17 years (n=3,030,970). The predictor
variable were the number of CCCs (0/1/2+) and the outcome variable was whether the child had a NTDC-related hospitalization (yes/no).
Descriptive statistics was generated and covariate-adjusted multi-variable logistic regression models were done to estimate pre-
valence odds ratios (PORs). There were less than one percent of NTDC-related hospitalizations of all hospital admissions, with a slightly
increased trend (not statistically significant) from year 2000 to 2010. There was no difference in odds of NTDCs for children with zero
or one CCCs, but there was a significant increase for children with 2+ CCCs, non-white, publicly insured and lower income. Post hoc
analyses revealed the average total charge for children with a NTDC-related hospitalization was $25,211 compared with $18,061 for
a non-NTDC-related hospitalization.
Comments: This study is the first published study to look at the non-traumatic dental conditions in pediatric inpatient hospitalizations.
Although the prevalence is low (averaging 0.59 percent from 2000 to 2010), the findings from this analysis are still valuable. It also
supports that patients with special health care need are indeed at higher risk of dental caries as stated in AAPD Caries-risk Assess-
ment Guideline. In addition, the cost of a NTDC-related hospitalization was much higher than a non-NTDC-related hospitalization,
which should encourage the focus on prevention for the children at higher risk in order to ultimately reduce the high cost associated
with hospitalization. It would be interesting to see the findings from each state which were not included in this study. KLH
Address correspondence to Dr. D.L Chi, University of Washington, Seattle, WA, USA; e-mail: [email protected]
Chi DL, Masterson EE. A serial cross-sectional study of pediatric inpatient hospitalizations for non-traumatic dental conditions.
J Dent Res 2013 Aug;92(8):682-8. doi: 10.1177/0022034513490733. Epub 2013 May 21.
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ATRAUMATIC RESTORATIVE TRE ATMENT (ART) 505

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