The suitability and effectiveness of the Art approach for people with disabilities

• Autores: Molina, Gustavo Fabían
• Año de publicación: 2014
• Idioma: inglés
• Tipo de recurso: libro
• Materia: Atraumatic restorative treatment; Dental care for the disabled; Caries; Glass ionomer cements
• Institución: Universidad Nacional de Córdoba

Fil: Molina, Gustavo Fabían. Universidad Nacional de Córdoba. Facultad de Odontología. Cátedra de Materiales Dentales; Argentina.
Caries is usually one of the many diseases on a long list of worrying conditions in people with physical and intellectual disability. Epidemiological data showed that people with disability present an equal to lower prevalence of dental caries but a higher prevalence of periodontal disease than experienced by comparable age groups among the general public. Major differences between the two groups include: lack of oral care, increased number of untreated tooth cavities and low utilization of preventive strategies in people belonging to the first group. Since the awareness of the importance of good oral health started to increase among patients with different impairments, implementation of preventing and/or treating caries lesions has faced several obstacles. These include: access to oral health care and barriers to caries treatment. They have lead the way to find feasible alternatives for improving oral health. Although health services systems and, particularly, caries treatment approaches vary from country to country, it is just to state that the utilization of dental services by people with disabilities is low worldwide which is reflected in their high unmet treatment needs. Therefore, alternative, less fearful preventive/therapeutic strategies are required aimed increasing access to oral care for a larger proportion of this population (Chapter 1). The first step in the process of arriving at an appropriate caries management concept for these people with disability was to carry out a systematic review into the existing preventive and therapeutic treatment regimes used (Chapter 2). Three databases were searched, covering the period January 1991 up to 1st February 2011. Randomized clinical trials, case-control, cohort studies and systematic reviews, published in English, Spanish, Portuguese, French and German languages were included for analysis. Only eight papers met the inclusion criteria; five referring to caries preventive, and three to restorative care programmes. Owing to the heterogeneity, quality, number, types and outcomes of the studies included in this review, it was not possible to extract a common strategy for the prevention and treatment of dental caries in people with disabilities. In light of the urgent need for such strategies for this population, it was suggested that international associations dealing with the production of scientific evidence, and those related to disability and oral health, should promote the development of quality research in order to propose guidelines for the prevention and treatment of dental caries in disabled people. The Atraumatic Restorative Treatment (ART) was suggested as a potentially useful concept in the treatment of persons requiring special care dentistry, although its use in this population was reported only once. However, if it is suggested that ART be a applied in a healthcare system for people with disability, its suitability and acceptance amongst care providers should first be investigated. Therefore, a study aiming at obtaining the opinions of experts in special care dentistry regarding these concerns was carried out amongst 30 experts from around the world who completed using a validated questionnaire survey (Chapter 3). All respondents reported having full or moderate knowledge of ART (23.3% and 63.3%, respectively), and 66.7% indicated that they felt that ART was useful for this population. However, only 50% of respondents used ART regularly in their practice and 5 (16.7%) replied that they would never use it, even if studies would show that ART was very effective in this population. The barriers to the introduction of ART to special care dentistry were discussed and one of the conclusions highlighted the need for training on ART and for further clinical research on its effectiveness and acceptance. High-viscosity glass-ionomers are the material mostly used with the ART approach. However, the oral cavity of people with disabilities functions, in general, differently than that of people without disability. A main concern, therefore, was finding the most appropriate restorative material that met the following features: easy to manipulate and fast setting with acceptable mechanical and biological properties. Finding a restorative glass-ionomer with improved mechanical properties than the current ones used with ART was, therefore, very important. At the time of proposing this PhD research project, two encapsulated high-viscosity glass ionomer restorative cements (EQUIA system and Chemfil Rock) had been launched on the market recently. These glass-ionomers were compared to traditional hand-mixed high-viscosity control materials (Fuji 9 Gold Label and Ketac Molar Easymix), for their diametral tensile, compressive and flexural strength (Chapter 4). Specimens for testing flexural (n=240) and diametral tensile (n=80) strength were prepared according to standardized specifications; compressive strength (n=80) was measured using a tooth-model of a class II ART restoration. ANOVA and Tukey B tests were used to test for significant differences between dependent and independent variables. The EQUIA system and Chemfil Rock had significantly higher mean scores for all the three strength variables than Fuji 9 Gold Label and Ketac Molar Easymix (α=0.05). The EQUIA system had significant higher mean scores for diametral tensile and flexural strengths than Chemfil Rock (α=0.05). It was concluded that the two encapsulated high-viscosity glass-ionomers had significantly higher test values for diametral tensile, flexural and compressive strength than the commonly used hand-mixed high-viscosity glass-ionomers. Although the in-vitro study demonstrated better mechanical properties for the encapsulated cements, it was suggested that early mechanical properties of high-viscosity glass-ionomer cements needed to be enhanced in order to achieve long term restoration survival rates in people with disabilities. A procedure to achieve this was through heating the cements during their setting reaction. Application of heat was obtained by the use of a high intensity LED curing lamp (1400mW/cm2). The aim of the in-vitro study was to investigate the effect of heating on the biaxial flexural strength (BFS), a more accurate method for assessing mechanical properties (Chapter 5). Samples of 2.1(SD±0.5) mm thick and 13 (SD±0.5)mm in diameter of Fuji 9 Gold Label, Ketac Molar Easymix (hand-mixed), Chemfil Rock and EQUIA system (encapsulated) were divided into three treatment groups of 30 samples each: 1) without heating, 2) heated with a LED-lamp of 1400 mW/cm2 for 30s and 3) with the same lamp for 60s while setting. Disc-shaped samples were prepared using polytetrafluoroethylene ring moulds placed on a polished glass slab covered with an acetate strip. Then a 1 kg glass slab was placed on top of the glass-ionomer cement to spread the material evenly throughout the ring. For treatment protocol groups 2 and 3, the glass slab was removed after 5s but leaving the acetate strip on top. The LED curing light was placed on top of the glass-ionomer cements, making contact with the acetate strip and light-cured the material either for 30s (group 2) or 60s (group 3). After heat curing, the glass slab was replaced over the mould. Samples were stored for 48 hours in distilled water at 37ºC until tested using a universal testing machine with a crosshead speed of 1mm/min. Data were analyzed using ANOVA test with Bonferroni correction (α=0.05). The mean BFS scores for the hand-mixed glass-ionomer cements were statistically significantly lower than those of the encapsulated glass-ionomer cements in all treatment groups. There was no statistically significant difference in mean BFS scores between the EQUIA system and Chemfil Rock at 30s and 60s (p>0.05). Heating the glass-ionomer cements with a LED curing lamp of 1400mW/cm2 during setting for 30s increased the BFS of high-viscosity glass ionomers, increasing its mechanical properties. Once the restorative materials have been selected, a pilot clinical trial was carried out to assess survival of ART restorations in patients with different medical conditions referred to the University Dental Hospital (Universidad Nacional de Córdoba) for caries treatment as well as to identify the suitability of this approach depending on their acceptance to the procedures. Sixty-six participants (patients/parents/caregivers) were provided with information regarding two therapeutic alternatives (ART and Conventional Approach), selecting one for approaching caries lesions in the patient. Patients were referred to General Anesthesia when the previous two alternatives were proved to be unfeasible. Reasons for the selection and for the need of a change (if appropriate) were recorded. Outcomes of the procedures in terms of difficulties and barriers were evaluated during the treatment sessions. Survival of restorations and level of satisfaction with the treatment provided were followed up at 12 months. Most of the participants chosen ART (n=48) as the treatment selected whereas conventional approach was carried out with or without general anesthesia. A total of 298 cavities were restored, 182 with ART and 126 using conventional approach. A high rate of success in the survival of restorations was found at 12 months follow up with no significant statistical differences between the two groups (Chapter 6). A higher level of satisfaction was registered as regards to the choices made by the ART group. It was concluded that the ART approach is an effective strategy to treat caries lesions in a variety of medical conditions where conventional approach is unfeasible. Patients/parents/caregivers were highly satisfied with the outcomes of their choice (Chapter 7).
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Fil: Molina, Gustavo Fabían. Universidad Nacional de Córdoba. Facultad de Odontología. Cátedra de Materiales Dentales; Argentina.
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