By Michael Long, BSDH, RDHAP
May 20, 2025

Early Childhood Caries (ECC) remains a significant public health concern, particularly affecting underserved populations worldwide.

 

Traditional restorative treatments often require local anesthesia, rotary instruments, and a clinical setting, making them less accessible to young children, those with special healthcare needs, and communities with limited dental care resources. Atraumatic and minimally invasive restorative techniques provide an effective alternative, prioritizing the preservation of tooth structure, patient comfort, and accessibility.

These techniques are easy to learn, patient-friendly, and consistent with the preventive philosophy of dental hygiene.

Dental hygienists play a vital role in preventing and managing ECC, and integrating these minimally invasive procedures into practice can greatly increase access to care. These techniques are easy to learn, patient-friendly, and consistent with the preventive philosophy of dental hygiene, making them a valuable addition to both clinical and community-based care settings.  This article explores the role of Atraumatic Restorative Treatment (ART), Interim Therapeutic Restorations (ITR), and Silver Diamine Fluoride (SDF) within the Silver-Modified Atraumatic Restorative Treatment (SMART) approach in managing ECC.

Atraumatic Restorative Treatment (ART)
ART is a minimally invasive caries management technique that involves manually removing decayed tooth material using hand instruments, followed by restoration with a high-viscosity glass ionomer cement (GIC). Developed by the World Health Organization (WHO), ART is widely used in community-based dental programs, schools, and low-resource settings due to its effectiveness and simplicity.1

Benefits of ART

  • Minimally Invasive: ART removes only infected dentin, preserving as much healthy tooth structure as possible.
  • No Need for Local Anesthesia or Rotary Instruments: Reduces fear and discomfort for pediatric patients.
  • Fluoride Release from GIC: Provides sustained caries protection through remineralization.
  • Cost-Effective and Accessible: Allows treatment in non-traditional settings, increasing access to care.

A systematic review demonstrated that ART restorations with high-viscosity glass ionomer cement have survival rates comparable to conventional restorations in primary teeth, making it a viable long-term solution.2

Interim Therapeutic Restorations (ITR) and the Role of the Dental Hygienist
Interim Therapeutic Restorations (ITR) share similarities with ART but are primarily used in cases where caries removal is incomplete. They serve as a temporary solution to stabilize the dentition until definitive treatment is available. Unlike ART, which is often a definitive treatment, ITR is used in a more temporary capacity.1

In many states across the U.S., dental hygienists with expanded function training are authorized to place ITRs under varying levels of supervision. This authorization enhances access to care by allowing dental hygienists to provide minimally invasive caries management in community settings, public health programs, and underserved areas. Their role in placing ITRs helps bridge the gaps in access to dental care, particularly for pediatric and special needs populations.

Silver Diamine Fluoride (SDF) and Its Role in Minimally Invasive Dentistry
Silver Diamine Fluoride (SDF) is a breakthrough in non-invasive caries management, particularly for young children, individuals with special healthcare needs, and those unable to undergo conventional restorative procedures. SDF arrests caries progression by penetrating dentin, killing cariogenic bacteria, and strengthening enamel through silver-protein and fluoride interactions.3

Silver-Modified Atraumatic Restorative Treatment (SMART)
SMART combines the benefits of ART and SDF, offering an effective, minimally invasive approach to managing caries in primary teeth. The protocol involves:

  1. Application of SDF to arrest caries progression.
  2. Placement of a high-viscosity glass ionomer restoration to seal the lesion.

This method provides antibacterial effects and mechanical protection, preventing lesion reactivation while preserving tooth structure. Studies indicate that SMART is an effective and durable option for managing caries in children who cannot tolerate conventional restorations.4

The Role of the Dental Hygienist in Atraumatic and Minimally Invasive Restorations
Dental hygienists are well-positioned to integrate atraumatic and minimally invasive restorative techniques into their practice. Their expertise in preventive and non-invasive treatments aligns perfectly with the philosophy of these procedures, enabling them to be effective providers for ART, ITR, and SMART in both community and clinical settings. Many states now permit dental hygienists, especially those with expanded function certifications, to place glass ionomer restorations, administer SDF, and perform ITRs under direct or indirect supervision.

Why Dental Hygienists Are Key Providers

  • Preventive Focus: Hygienists emphasize prevention, patient education, and early intervention, reducing the need for more invasive treatments.
  • Community-Based Care: RDHAPs and public health hygienists serve in non-traditional settings, increasing access to care for underserved populations.
  • Minimally Invasive Approach: Their training in non-invasive procedures allows for effective caries management with minimal patient discomfort.
  • Cost-Effective and Scalable: Utilizing dental hygienists for ART, ITR, and SMART expands care reach while lowering costs in public health programs.


As the dental profession shifts towards minimally invasive and preventive care models, broadening the scope of practice for dental hygienists in these areas can help address disparities in oral health and reduce the burden of ECC nationwide.

Conclusion
Atraumatic and minimally invasive restorative techniques, including ART, ITR, SDF, and SMART, provide effective alternatives to traditional restorative treatment, expanding access to care for vulnerable populations. These approaches align with the principles of minimally invasive dentistry, prioritizing tooth preservation, patient comfort, and disease prevention. As more dental hygienists and alternative practice providers integrate these techniques into community care settings, the management of ECC can become more accessible and person-centered.

____________________________________

References

1J. E. Frencken et al., “Survival of ART Restorations: A Meta-analysis,” Clinical Oral Investigations 16, no. 2 (2012): 429-441.

2American Academy of Pediatric Dentistry, “Guidelines on Caries Risk Assessment and Management for Infants, Children, and Adolescents,” American Academy of Pediatric Dentistry Reference Manual (2023).

3J. A. Horst, H. Ellenikiotis, and P. L. Milgrom, “UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications, and Consent,” Journal of the California Dental Association 44, no. 1 (2016): 16-28.

4J. Clemens, J. Gold, and J. Chaffin, “Effectiveness of Silver Diamine Fluoride and the SMART Technique in Arresting Caries in Primary Teeth,” Journal of the American Dental Association 149, no. 8 (2018): 628-636.

____________________________________


Michael Long, BSDH, RDHAP has been a proud member of the American Dental Hygienists’ Association since 2004. A registered dental hygienist in California, he works in private practice and serves as part-time clinical faculty at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. In 2023, he was honored to be appointed by Governor Gavin Newsom to the Dental Hygiene Board of California.