The Box

April 1, 2004
You know about The Box, right? Everyone talks about people who think outside of The Box. We have a negative opinion of those inside The Box who cannot think outside of it.

by Shirley Gutkowski

You know about The Box, right? Everyone talks about people who think outside of The Box. We have a negative opinion of those inside The Box who cannot think outside of it. Thinking or being outside of The Box is uncomfortable for many people. Box Dwellers are those who like conformity, enjoy and value rules, and live quite happily within the confines of them.

What is The Box exactly? Well, it's this:

A brainteaser. The object is to connect the dots without going over the same line twice or removing your pen from the paper. The four corner dots represent The Box. One can spend all day trying different combinations of lines to make this brainteaser work. Line after line, people cross this one and that one until they give up. They turn to the back of the book to figure out how to make the puzzle work.

The trick is to extend one line out of The Box, then come back into it.

For example, start at any point, say the upper right-hand dot, and connect three of dots. Then, instead of going to the fourth dot, extend the line — going out of the space altogether. Then finish with the final four lines.

That's how progress happens; someone thinks of a totally different way to look at an issue. They may not see a problem or challenge at all. These freethinkers come in with an approach that defies the ruling logic and resists conformity. For them, the answer is obvious. A good example of this type of freethinking is the marriage of glass ionomers and something called ART, an acronym for atraumatic restorative treatment, a treatment modality that can save teeth in the hygiene department.

Here's some background on the whole shebang. ART was developed for use in Third World countries where electricity was scarce or non-existent.1 Dental missionaries would go into villages and extract teeth during daylight hours. There was no way to save teeth, even if the decay was small. Compared to our American standards, the villagers were treated even worse than the indigent in Hometown, USA. Tooth extraction was the only option for the villagers; tooth replacement was all but unheard of.

Dental teams traveled into these backward villages only once a year or less. They did what they could — or what they had to — to get the villagers out of pain. Without electricity, there were no lights or handpieces. Without handpieces, decay could not be removed satisfactorily and the teeth could not be properly prepared to accept a friction/mechanically-retained restoration. There had to be a better way.

Meanwhile, a product called glass ionomer (GI) was being developed as a therapeutic restorative material. It bonds chemically to enamel and dentin, is moisture friendly, and releases fluoride, which is the biggest benefit. The fluoride is not a structural component of the substance, so the material releases it continuously.2 For First World countries, GI works as a fluoride battery, meaning it can be recharged with fluoride from the environment, such as toothpaste. For the Third World countries, where fluoride is scarce, it just keeps pumping out fluoride, tapering off over the next two years or so.

Eventually the two projects came together and the procedure called atraumatic restorative treatment was born — the equivalent of the person working on the brainteaser puzzle realizing that he could go outside of the square to complete the puzzle. The decay would be removed with a hand instrument, until all the soft debris was removed. Then the glass ionomer restorative material would be placed. The procedure worked. It worked for years. Form and function could be returned to teeth that otherwise would have been extracted. Decades of dental advancement took a different turn. Instead of cutting better preparations with advanced rotary instruments to retain inactive materials, the materials evolved to the point where perfect preparations were less important. The substance bonded directly to enamel and the fluoride release arrested the remainder of decay. Glass ionomers are a dynamic restorative material.

Studies showed the material was still present six years after placement.3 The studies also told us that in a split mouth study design, the GI materials longevity in a Class I restoration was about the same as amalgam placed with traditional methods.4 The bonus was a statistically significant finding: recurrent decay around the GI material occurred statistically much less often than the amalgam fillings.

Here's where it becomes interesting to the clinical hygienist in the United States where pockets of Third World conditions exist. Researchers worked on using GI as a sealant for teeth. Not for the regular, run-of-the-mill patient, but for high-caries risk patients. As they worked on developing glass ionomers for sealants, certain problems arose and were overcome. Today, we have one sealant material made of glass ionomer that releases six times the amount of fluoride that the earlier generations of glass ionomers did. It's called Triage.

Hold on — the news flash isn't finished. The pen is now heading outside of The Box. Traditionally, sealants have been placed on the occlusal surface of teeth, filling the pits and fissures with a composite resin material forming a physical barrier to biofilms. There are certain limitations to using traditional sealants. For instance, the tooth has to be erupted far enough into the mouth to make access possible and the patient has to cooperate. Traditional resin sealants require multiple steps and adhere to the tooth with a mechanical bond, limiting the placement to a horizontal surface.

Many oral health-care providers dreamed of placing a sealant on the buccal surface of a tooth that never felt the prickle of toothbrush bristles. Patients who couldn't, for whatever reason, clean broad surfaces of teeth couldn't be fully protected by traditional sealants. The researchers found GI could be used on the broad, or vertical, surfaces to protect the teeth from biofilm excrement. Biofilms do not grow on glass ionomer materials.5 Therefore, the tooth is protected on a molecular level with the fluoride, and on a macro level by a physical barrier to biofilm and food, and with an environment low in pH.

The benefits of GI as a surface protectant are useful for all dependent populations. Children, adults with disabilities, and the elderly can benefit from this material. Imagine children who are fearful because of the learned response from their mothers. Using ART could keep the fear from escalating even further. Temporary fillings are within the scope of practice for hygienists in most states. Filling frank decay in a child using this protocol may keep the tooth safe until it either falls out or becomes infected at another location. For adults in the last stages of life, a restorative material that lasts six years may be enough.

Traveling outside The Box is what keeps dental hygiene interesting, and keeps our patients attached to their teeth for a longer time. While the phrase may be over-used, the idea is so important that it'll be around for a long time.

Shirley Gutkowski, RDH, BSDH, has been a practicing dental hygienist since 1986. She is a popular speaker and award-winning author. Gutkowski and Amy Nieves, RDH, are the co-authors of "The Purple Guide: Developing Your Dental Hygiene Career," a handbook for graduates from dental hygiene school. Gutkowski can be contacted at [email protected].

1 Frencken J. Manual for the Atraumatic Restorative Treatment approach to control dental caries, WHO Collaborating Center for Oral Health Services Research, Groningen
2 Croll T, Nicholson J. "Glass ionomer cements in pediatric dentistry: review of the literature." Ped Dent 2002; 24(5): 423-9
3 Mandari GJ, Frencken J, van't Hof MA. "Six-year success rates of occlusal amalgam and glass-ionomer restorations placed using three minimal intervention approaches." Caries Res 2003; 37(4):246-53
4 Honkala E, Behbehani J, Ibricevic H, Kerosulo E, Al-Jame G. "The atraumatic restorative treatment (ART) approach to restoring primary teeth in a standard dental clinic." Int J Paed Dent 2003: 13
5 Berg J, Ferral J, Brown L. "Class II glass ionomer/silver cermet restorations and their effect on interproximal growth of mutans streptococci." Ped Dent 1990; 12(1): 20-3
For more references, go to and use the search terms: ART, glass ionomer OR glass ionomer, caries OR Atraumatic Restorative Treatment.