System dynamics modeling for tooth decay treatment in Brazilian children

Abstract

Prevention and health promotion are considered important strategies to control oral diseases. Dental caries is preventable disease and remains the most common chronic disease that affects mainly low income children and still considered the main cause of tooth loss in adulthood in Brazil. The aim of this study is to present a System Dynamics model (SDM) specifically developed with the Stella Architect software to estimate the cost and clinical hours required to control the evolution of dental caries in preschool children in Maringá, Brazil. Two main strategies to control caries were considered in the model: the application of fluoride varnish on teeth presenting white spots, and the use of Atraumatic Restorative Treatment (ART) in cavitated carious lesions without pulp involvement. The parameters used in the model were: number of people covered by a local oral health team = 4,000; number of children up to 5 years = 7% of the population; children’s decayed, missing, filled teeth (dmft) index = 2.4; time/cost of 4 applications of fluoride varnish = 5 minutes/US$ 0.716; and time/cost of each ART restoration = 15 minutes/US$ 1.475. The SDM generated an estimated total cost of US$698.00, and a total of 112 clinical hours to treat the population in question. The use of the SDM presented here has the potential to assist decision making by measuring the material and human resources required to prevent and control dental caries at an early age.

Systems Analysis; Dental Caries; Dentists; Dental Atraumatic Restorative Treatment

Introduction

Oral health education, especially during childhood, can be a powerful ally to prevent chronic diseases, such as dental caries, which are triggered by the high consumption of free sugars present in their diet. ¹ The acquisition of healthy habits promoted by oral health education, in association with programs to control dental caries evolution, can prevent future tooth loss during adulthood. ² In Brazil, for instance, while children up to 5 years present a mean decayed, missing, filled teeth (dmft) index of 2.43, people aged between 65 and 74 years show a mean DMFT of 27.53, with high prevalence of tooth loss. ³ In the 2010 Global Burden of Disease study, among 291 evaluated diseases, untreated caries in permanent teeth was considered the most prevalent condition worldwide, and the untreated caries in deciduous teeth were the 10th most prevalent condition. ⁴

Additionally, in Brazil caries can also vary according to the socioeconomic condition, affecting mainly the low income population. ⁵ , ⁶ Inequalities in access to healthcare services represent one of the main challenges faced by health provision policymakers. To minimize the social differences and improve basic healthcare provision in Brazil, the Family Health Strategy (FHS) was created in 1994, initially denominated as Family Health Program (FHP). ⁷ Basically, the FHS consists of teams of health professionals that visit the population within a particular geographical area, aiming at disease prevention, treatment, and rehabilitation. ⁸ The oral health teams started implementation by Portaria GM 1,444 ⁹ with regulation by Portaria GM 267. ¹⁰ In 2004, the Brazilian Oral Health Policy, also known as Smiling Brazil , was established to pursue universal oral care within the Brazilian Unified Health System. ¹¹ Since then, emphasis has been placed on interventional educational approaches and preventive programs, which are considered the priority to deal with chronic diseases, such as dental caries. Nonetheless, early childhood caries (ECC) is still considered a significant public health problem, particularly among the most socially and economically disadvantaged minorities. ¹² , ⁶

Educational activities involving patients are the main components of the preventive philosophy, empowering people with knowledge about health/disease processes for the development of autonomous oral health self-care within the family context. ¹³ Because the costs of treating oral diseases are also associated to indirect costs, such as productivity losses due to absenteeism from work, ¹⁴ actions to prevent and control caries early in life are important instruments to maintain oral health later in adulthood. Moreover, parents/guardians often report the heavy financial burden involved in seeking oral treatment late, especially when pain is present. ¹⁵

System Dynamics modeling is well suited to deal with public health issues, giving support to public policy planning, by estimating future demands and resources. ¹⁶ Thus, different scenarios emerging from epidemiological surveys can be more promptly and appropriately dealt with. Because public health interventions tend to operate in dynamically complex systems, decision making processes require tools that can provide support to public policy planning, estimating future demands and resources. System dynamics is a methodology and mathematical modeling technique developed to frame, understand, and discuss complex issues and problems. Recently, system dynamics modeling has been used to better understand the effects of preventive programs in complex health systems and their impact on the health status of populations. ¹⁷

Therefore, the objective of the present study is to present a System Dynamics model (SDM) specifically developed to estimate the cost and clinical hours required to control the development of dental caries lesions in preschool children in Brazil.

Methodology

In the present study, an SDM was developed to estimate the costs and the clinical hours required for the treatment of preschool children up to 5 years with white spots and cavitated carious lesions using either fluoride varnish or ART, depending on the stage of the disease.

System dynamics model

The SDM used in this study was developed using the Stella Architect software. The SDM was created using stock and flow diagrams. Stocks are cumulative resources of a system, while flows represent the rate of change of a stock ¹⁸ ( Figure 1 ). In the present study, the stocks were represented by “teeth with carious lesions”, “teeth with white spots”, and “total material costs”.

Figure 1
Basic components of one representative stock and flow diagram of System Dynamics model.

SDM development started with the establishment of a systemic vision of the problem, participation in courses and events, discussions, and exchange of information and experiences with specialists in system dynamics modeling. Based on this systemic vision, data from oral educational and preventive actions conducted at an Early Childhood Education Center in the city of Maringá, Brazil were used to define the goals (unpublished data).

The first step for SDM development was a diagram of inventories and flows created by the team of researchers, containing the main ideas and data. Based on this initial diagram, sketches of the model were drawn. A specialist in engineering, mathematics, statistics, and system dynamics was consulted, and all the required adjustments were conducted so that the SDM would respond to the established goals. Emphasis was placed on developing an SDM that was simple, as well as easy to understand and apply to a range of local realities by health managers and professionals.

Cost and clinical hours estimation

The application of fluoride varnish and ART restorations were conducted by an oral health team (OHT), composed by a dentist, an oral health technician, and an oral health assistant. ¹⁰ OHT salaries, as well as the equipment and instrumentation already in use were not considered in the model, as these are fixed costs that already existed regardless of the interventions proposed. Only the cost of the materials for the treatment of white spots and cavitated carious lesions using either fluoride varnish (S.S. White Artigos Dentários Ltda, Rio de Janeiro, Brazil) or the high-viscosity glass ionomer (Ketac Molar EasyMix, 3M ESPE, Sumaré, Brazil) used in the ART restorations were considered in the model. Prices currently practiced in the market were obtained from “Banco de Preços em Saúde” (http://www.saude.gov.br/gestao-do-sus/economia-da-saude/banco-de-precos-em-saude), and “Painel de Preços” (http://paineldeprecos.planejamento.gov.br/) website.

To determine the time involved in the procedures, the proposed interventions were performed in children up to 5 years attending an Early Childhood Education Center in the city of Maringá. The procedures were conducted after parents/legal guardians signed an informed consent. An initial epidemiological survey was conducted by calibrated researchers, and the International Caries Detection and Assessment System (ICDAS) index was used to allocate the children according to their risk group, prioritizing care to those at higher risk. ¹⁹ Children presenting teeth with white spots were treated with 4 applications of fluoride varnish over a period of 1 month (once for week). Children with cavitated carious lesions were treated with ART. Children presenting advanced carious lesions with pulp involvement were sent to a Basic Healthcare Unit for specialized care.

SDM input parameters

Once all the data were collected, the following parameters were fed into the SDM:

1. Population: 4000 inhabitants - the average number of people served by each FHS-OHT team (According to personal communication with Maringa oral health coordinator);

2. Number of children aged up to 5 years in the area: 7% of the general population - estimated for the city of Maringá (data supplied by the Brazilian Statistics Institute);

3. Mean dmft of the children aged up to 5 years in Paraná State: 2.4; ³ , ²⁰

4. Mean time required for 4 applications of fluoride varnish: 5 minutes;

5. Mean time required for each ART restoration: 15 minutes;

6. Cost of 4 applications of fluoride varnish: US$ 0.179 (each) x 4 = US$ 0.716 ( Table 1 );

   Table 1
   Cost calculation for the application of Fluoride Varnish.
   

   Item	Price (unity)	Manufacturer	Use	Applications	Cost/ application
   Fluoride Varnish 5%	U$ 3.62 (15 ml)	S.S. White Artigos Dentários Ltda	100 µl/application	150	U$ 0.005
   Microbrush	U$ 1.79 (100 unities)	Dentscare Ltda	1/application	100	U$ 0.018
   Cotton pellets	U$ 0.34 (100 unities)	SS Plus do Brasil Ltda	5/children	20	U$ 0.017
   Surgical gloves	U$ 4.74 (100 unities)	Descarpack Descartáveis do Brasil Ltda	1 pair/application	50	U$ 0.095
   Surgical Masks	U$ 1.40 (50 unities)	Descarpack Descartáveis do Brasil Ltda	1/child	50	U$ 0.028
   Glengarry	U$ 1.66 (100 unities)	Descarpack Descartáveis do Brasil Ltda	1/child	100	U$ 0.017
   Total cost/fluoride vanish application					U$ 0.179

   Source: Prices obtained from “Banco de Preços em Saúde” (http://www.saude.gov.br/gestao-do-sus/economia-da-saude/banco-de-precos-em-saude), and “Painel de Preços” (http://paineldeprecos.planejamento.gov.br/) website in November, 2019.

7. Cost of each ART restoration: US$ 1.475 ( Table 2 ).

   Table 2
   Cost calculation for ART procedures using high-viscosity glass ionomer.
   

   Item	Price (unity)	Manufacturer	Use	Applications	Cost
   Glass ionomer	U$ 73.75 (12.5 g)	Ketac Molar EasyMix, 3M ESPE	0.20 g/ART	62.5	U$ 1.180
   Cotton rolls	U$ 0.34 (100 unities)	SS Plus do Brasil Ltda	5/children	20	U$ 0.017
   Dental Floss	U$ 1.85 (500 m)	Hillo - Industria e Comercio Ltda	0.20 m/ART	2500	U$ 0.001
   Surgical masks	U$ 1.40 (50 unities)	Descarpack Descartaveis do Brasil Ltda	1/ART	50	U$ 0.028
   Surgical gloves	U$ 4.74 (100 unities)	Descarpack Descartaveis do Brasil Ltda	1 pair/ART	50	U$ 0.095
   Glengarry	U$ 1.66 (100 unities)	Descarpack Descartaveis do Brasil Ltda	1 glengarry/child	100	U$ 0.017
   Polyacrylic acid conditioner 11.5%	U$ 7.39 (10 ml)	D.C.M.A. Produtos Medicos e Odontologicos Ltda	0.05 ml/ART	200	U$ 0.037
   Calcium hydroxide (Hidro C)	U$ 4.35 (10 g)	Dentsply Industria e Comercio Ltda	0.05 g/ART	600	U$ 0.022
   Solid vaseline	U$ 7.40 (500 g )	Industria Farmaceutica Rioquímica Ltda	0.05 g/ART	10000	U$ 0.001
   Polyester matrix	50 unities U$ 1.50	Preven Industria e Comercio de Produtos Odontologicos Eireli	1/ART	150	U$ 0.005
   Microbrush	100 unities U$ 1.79	Dentscare Ltda	1/ART	100	U$ 0.018
   Carbon paper	12 unities U$ 0.61	Preven Industria e Comercio de Produtos Odontologicos Eireli	1/ART	12	U$ 0.050
   Disposable coffee cups	U$ 0.38 (100 unities)	TY Bortholin Comercial Ltda	1/ART	100	U$ 0.004
   Total cost/Art					U$ 1.475

   Source: Prices obtained from “Banco de Preços em Saúde” (http://www.saude.gov.br/gestao-do-sus/economia-da-saude/banco-de-precos-em-saude), and “Painel de Preços” (http://paineldeprecos.planejamento.gov.br/) website in November, 2019.

Results

The material involved in the application of fluoride varnish is presented in Table 1 , while the material for ART restorations is presented in Table 2 .

The SDM developed with Stella Architect software is illustrated in Figure 2 . The SDM, together with instructions for use, is freely available at https://exchange.iseesystems.com/public/karim/art-treatment.

Figure 2
System Dynamics Model to estimate the cost and clinical hours required to control dental caries in preschoolers conducted by a local oral health team.

After inputting all the required parameters, the total cost for controlling caries in preschoolers within an area of 4000 inhabitants, conducted by the local OHT, was estimated by the SDM at US$ 698.00. This total amount included 4 applications of fluoride varnish, and the conduction of ART restorations as required. The clinical time estimated for the application of fluoride varnish was 14 hours, while for ART restorations it was 98 hours ( Figure 3 ).

Figure 3
System Dynamics Model demonstrating the relationship between clinical time and cost required to control dental caries conducted by a local oral health team.

Discussion

This study presents an SDM that was developed to estimate the costs and clinical hours required to control the evolution of carious lesions in preschool children within a geographical area served by an OHT in the city of Maringá, Brazil. The results of this study demonstrated that making use of preventive and curative actions at the early stages of dental caries does not necessarily involve large investments or clinical time, as the total cost for controlling caries in preschoolers estimated by the SDM was US$ 698.00.

The impact of preventive programs for the control and reduction of caries has been widely recognized. ¹⁷ However, preventive programs alone may have limited effect on more advanced stages of dental caries. In a previous study, SDM was used to evaluate the relative effect and cost of six different types of ECC treatment: application of fluoride; limiting cariogenic bacterial transmission; use of xylitol; clinical treatment; motivational interviewing; and a combination of these. The authors observed that combined interventions showed the greatest potential for the reduction of carious lesions, considering that interventions on children at the highest risk resulted in the highest return on the investment. ¹⁷

Apart from preventive measures, alternative strategies have been developed to improve the oral health of children with the adoption of curative treatments whenever required. ²¹ Two different interventions on carious lesions were considered in the present study as part of a strategy to control the disease in preschool children. Teeth presenting white spots were treated with fluoride varnish, while cavitated carious lesions without pulp involvement were treated with ART. These interventions were performed by an OHT composed by a dentist, an oral health technician, and an oral health assistant. The OHT works within a designated geographical area, so that the most vulnerable populations can have access to oral care. This strategy controls the disease at lower costs and maximizes clinical time. In the present study, the children were treated in their own school in a specially prepared room under natural lighting during OHT visits. Because of the familiar surroundings, children feel minor or no stress and anxiety, facilitating treatment. ²² , ²³

The efficacy of fluoride varnish applied on teeth presenting white spots has been well established. The application of fluoride varnish promotes the remineralization process and control the evolution of caries. ²⁴ Its application is simple, fast, and, as observed in the present study, quite inexpensive. When applied at early stages, it can substantially assist in the preservation of the dentition in the long term. When cavitated carious lesions are present at an early age, also known as “early childhood caries”, the treatment may be made more difficult because of the lack of cooperation from the child, sometimes requiring the use of general anesthesia. ²⁵ ART is a minimally invasive technique that preserves healthy tooth structure by selectively removing carious tissues with hand instruments. ²⁶ Later, cavities are restored with glass ionomer cement (GIC), preventing the exposure of the pulp. The procedure arrests the evolution of dental caries and prevents the need for canal filling and extractions, preserving the primary dentition until exfoliation. ²² Studies have demonstrated good survival/success rates of ART restorations in primary teeth ²⁷ , ²⁸ and also in the permanent dentition. ²⁹ , ³⁰ ART has a broad social impact, reducing costs and clinical time. ³¹ , ³² It has been described as an economical and effective method to prevent dental caries progression in vulnerable populations. ³³ Because it only uses hand instruments, ART does not require the infrastructure of a dental office and can be performed in locations where conventional treatment is not possible or access is precarious. Moreover, because the procedure rarely causes pain, anesthesia is not required. ²³

In another study of our group ³⁴ , System Dynamic modeling was useful to simulate the impact of preventive and educational approaches on the maintenance of people’s teeth throughout their lives. This study demonstrated that the acquisition of health habits though educational approaches could result in the increase of number of people with no tooth loss, improving quality of life.

As observed in the present study, the SDM can be used to justify preventive policies within an existing system. SDM can show that certain interventions may not necessarily involve excessive cost or be time-consuming. One important limitation, however, concerns the fact that even small SDMs, such as the one presented here, are not simple to develop. It demands a very careful and systematic analysis of the problems targeted and the support of experts. Only after extensive trial and error, the final version of the SDM responded as expected. Nonetheless, once developed, the model in the present study may be used in different locations with people needing treatment, with similar problems by simply inputting that location’s own data.

Conclusion

SDM can represent a powerful tool in Dentistry with the potential to assist decision making by measuring the material and human resources required to prevent and control dental caries at an early age. Early diagnosis and treatment of dental caries lesions with the application of fluoride varnish and ART treatment on preschool children has been shown to be a viable strategy without incurring high costs.

Acknowledgements

This study was funded by grants from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – CAPES (Financing Code 001), PROCAD/CAPES (Proc. 88881.068416/2014-01), and Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq (Proc. 401514/2013-7).

References

• ¹
  Sheiham A, James WP. Diet and dental caries: the pivotal role of free sugars reemphasized. J Dent Res. 2015 Oct;94(10):1341-7. https://doi.org/10.1177/0022034515590377
  » https://doi.org/10.1177/0022034515590377
• ²
  Roncalli AG, Sheiham A, Tsakos G, Araújo-Souza GC, Watt RG. Social factors associated with the decline in caries in brazilian children between 1996 and 2010. Caries Res. 2016;50(6):551-9. https://doi.org/10.1159/000442899
  » https://doi.org/10.1159/000442899
• ³
  Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. SB Brasil 2010: Pesquisa Nacional de Saúde Bucal: resultados principais. Brasília, DF: Ministério da Saúde. 2012.
• ⁴
  Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, et al. Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent Res. 2013 Jul;92(7):592-7. https://doi.org/10.1177/0022034513490168
  » https://doi.org/10.1177/0022034513490168
• ⁵
  Pattussi MP, Marcenes W, Croucher R, Sheiham A. Social deprivation, income inequality, social cohesion and dental caries in Brazilian school children. Soc Sci Med. 2001 Oct;53(7):915-25. https://doi.org/10.1016/S0277-9536(00)00391-9
  » https://doi.org/10.1016/S0277-9536(00)00391-9
• ⁶
  Piovesan C, Mendes FM, Ferreira FV, Guedes RS, Ardenghi TM. Socioeconomic inequalities in the distribution of dental caries in Brazilian preschool children. J Public Health Dent. 2010;70(4):319-26. https://doi.org/10.1111/j.1752-7325.2010.00191.x
  » https://doi.org/10.1111/j.1752-7325.2010.00191.x
• ⁷
  Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Coordenação de Saúde da Comunidade. Saúde da família: uma estratégia para a reorientação do modelo assistencial. Brasília, DF: Ministério da Saúde; 1997.
• ⁸
  Ministério da Saúde (BR). Secretaria da Atenção Básica à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção. 4a ed. Brasília, DF: Ministério da Saúde; 2007. (Série Pactos pela saúde 2006, v. 4).
• ⁹
  Ministério da Saúde (BR). Portaria N ^o 1444/GM, de 28 de dezembro de 2000. Estabelece incentivo financeiro para a reorganização da atenção à saúde bucal prestada nos municípios por meio do Programa de Saúde da Família. Diário Oficial União. 2000 Dec 28.
• ¹⁰
  Ministério da Saúde (BR). Portaria N ^o 267/GM, de 6 de março de 2001. Aprova as normas e diretrizes de inclusão da saúde bucal na estratégia do Programa Saúde da Família. Diário Oficial União. 2001 Mar 6.
• ¹¹
  Pucca GA Jr, Gabriel M, de Araújo ME, de Almeida FC. Ten years of a national oral health policy in Brazil: innovation, boldness, and numerous challenges. J Dent Res. 2015 Oct;94(10):1333-7. https://doi.org/10.1177/0022034515599979
  » https://doi.org/10.1177/0022034515599979
• ¹²
  Ardenghi TM, Sheiham A, Marcenes W, Oliveira LB, Bönecker M. Maxillary anterior caries as a predictor of posterior caries in the primary dentition in preschool Brazilian children. J Dent Child (Chic). 2008 Sep-Dec;75(3):215-21.
• ¹³
  Galbiatti F, Gimenez CM, Moraes AB. Odontologia na primeira infância: sugestões para a clínica do dia-a-dia. J Bras Odontopediatr Odontol Bebê. 2002;5(28):512-7.
• ¹⁴
  Listl S, Galloway J, Mossey PA, Marcenes W. Global economic impact of dental diseases. J Dent Res. 2015 Oct;94(10):1355-61. https://doi.org/10.1177/0022034515602879
  » https://doi.org/10.1177/0022034515602879
• ¹⁵
  Ribeiro GL, Gomes MC, Lima KC, Martins CC, Paiva SM, Granville-Garcia AF. [The potential financial impact of oral health problems in the families of preschool children]. Cien Saude Colet. 2016 Apr;21(4):1217-26. Portuguese. https://doi.org/10.1590/1413-81232015214.09512015
  » https://doi.org/10.1590/1413-81232015214.09512015
• ¹⁶
  Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. Am J Public Health. 2006 Mar;96(3):452-8. https://doi.org/10.2105/AJPH.2005.062059
  » https://doi.org/10.2105/AJPH.2005.062059
• ¹⁷
  Hirsch GB, Edelstein BL, Frosh M, Anselmo T. A simulation model for designing effective interventions in early childhood caries. Prev Chronic Dis. 2012;9:E66. https://doi.org/10.5888/pcd9.110219
  » https://doi.org/10.5888/pcd9.110219
• ¹⁸
  Forrester JW. Industrial dynamics. Cambridge: MIT Press; 1961.
• ¹⁹
  Pitts NB, Ekstrand KR. Methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol. 2013 Feb;41(1):e41-52. https://doi.org/10.1111/cdoe.12025
  » https://doi.org/10.1111/cdoe.12025
• ²⁰
  Berti M, Furlanetto DL, Walker MM, Baltazar MM, Bianchi FJ. [Epidemiological survey of dental caries in children with 5 and 12 years of age of Cascavel, PR]. Cad Saude Colet. 2013;21(4):403-64. Portuguese. https://doi.org/10.1590/S1414-462X2013000400007
  » https://doi.org/10.1590/S1414-462X2013000400007
• ²¹
  Monnerat AF, Souza MI, Monnerat AB. Atraumatic restorative treatment. Can we trust in this technique? Rev Bras Odontol. 2013;70(1):33-6.
• ²²
  Mickenautsch S, Frencken JE, van’t HM. Atraumatic restorative treatment and dental anxiety in outpatients attending public oral health clinics in South Africa. J Public Health Dent. 2007;67(3):179-84. https://doi.org/10.1111/j.1752-7325.2007.00017.x
  » https://doi.org/10.1111/j.1752-7325.2007.00017.x
• ²³
  Frencken JE, Leal SC, Navarro MF. Twenty-five-year atraumatic restorative treatment (ART) approach: a comprehensive overview. Clin Oral Investig. 2012 Oct;16(5):1337-46. https://doi.org/10.1007/s00784-012-0783-4
  » https://doi.org/10.1007/s00784-012-0783-4
• ²⁴
  Weyant RJ, Tracy SL, Anselmo TT, Beltrán-Aguilar ED, Donly KJ, Frese WA, et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc. 2013 Nov;144(12):1279-91. https://doi.org/10.14219/jada.archive.2013.0057
  » https://doi.org/10.14219/jada.archive.2013.0057
• ²⁵
  Tuli A, Singh A. Early childhood caries and oral rehabilitation. A treatment quandary. Eur J Paediatr Dent. 2010 Dec;11(4):181-4.
• ²⁶
  Holmgren CJ, Roux D, Doméjean S. Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART): a minimum intervention and minimally invasive approach for the management of dental caries. Br Dent J. 2013 Jan;214(1):11-8. https://doi.org/10.1038/sj.bdj.2012.1175
  » https://doi.org/10.1038/sj.bdj.2012.1175
• ²⁷
  Amorim RG, Leal SC, Frencken JE. Survival os atraumatic restorative treatment (ART) sealants and restorations: a meta-analysis. Clin Oral Investig. 2012; 16(2):429-441. https://doi.org/10.1007/s00784-011-0513-3
  » https://doi.org/10.1007/s00784-011-0513-3
• ²⁸
  Raggio DP, Hesse D, Lenzi TL, Guglielmi CA, Braga MM. Is atraumatic restorative treatment an option for restoring occlusoproximal caries lesions in primary teeth? A systematic review and meta-analysis. Int J Paediatr Dent. 2013;23(6):435-46. https://doi.org/10.1111/ipd.12013
  » https://doi.org/10.1111/ipd.12013
• ²⁹
  Taifour D, Frencken JE, Beiruti N, van’t Hof MA, Truin GJ, Palenstein Helderman WH. Comparison between restorations in the permanent dentition produced by hand and rotary instrumentation—survival after 3 years. Community Dent Oral Epidemiol. 2003 Apr;31(2):122-8. https://doi.org/10.1034/j.1600-0528.2003.00027.x
  » https://doi.org/10.1034/j.1600-0528.2003.00027.x
• ³⁰
  Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011 Apr;15(2):265-71. https://doi.org/10.1007/s00784-009-0378-x
  » https://doi.org/10.1007/s00784-009-0378-x
• ³¹
  Mickenautsch S, Munshi I, Grossman ES. Comparative cost of ART and conventional treatment within a dental school clinic. SADJ. 2002 Feb;57(2):52-8.
• ³²
  Tonmukayakul U, Arrow P. Cost-effectiveness analysis of the atraumatic restorative treatment-based approach to managing early childhood caries. Community Dent Oral Epidemiol. 2017 Feb;45(1):92-100. https://doi.org/10.1111/cdoe.12265
  » https://doi.org/10.1111/cdoe.12265
• ³³
  Frencken JE1, Pilot T, Songpaisan Y, Phantumvanit P. Atraumatic Restorative Treatment (ART): rationale, technique and development. J. Public Health Dent. 1996; 56(3 Spec No):135-40.
• ³⁴
  Fujimaki M, Umeda JE, Terada RS, Brito T, Pietrobon R, Passos G. Understanding why caries is still a public health problem. System Dynamics Society; 2015 [cited 2019 Sept 23]. Available from: https://www.systemdynamics.org/oral-health
  » https://www.systemdynamics.org/oral-health

Publication Dates

• Publication in this collection
  27 Feb 2020
• Date of issue
  2020

History

• Received
  15 Oct 2019
• Accepted
  20 Jan 2020
• Reviewed
  27 Jan 2020