Nine experiences that evaluated ART implementation steps as public policy were identified and reported in 20 articles. It is not known whether the technique has been used (in specific actions and research projects, without the involvement of decision makers for inclusion in the political agenda, or if the strategy is used as a policy but without evaluation and publication of the results in the scientific literature), in addition to the experiences presented, managers affirm that ART is included in national oral health policies in countries such as Brazil, Chile, Ecuador, Peru, Uruguay, and in the agenda of dentistry schools in countries such as Argentina, Brazil, Ecuador, Peru, and Venezuela34.
Regarding the context for implementing ART in public oral health policies, studies share common problems, such as the high prevalence of dental caries and the lack of access to restorative procedures in health services, aggravated by inequities in access, which reinforces social differences. Another problem recognized by the scientific literature is the difficulty in moving users to perform treatments for caries lesions with shallow and medium cavities when there is still no report of pain. The scientific literature mentions dental consultations scheduled when patients study or work, fear of losing their jobs, misery, and lack of information as the primary causes of absenteeism35–37. The late treatment of oral health problems results in unnecessary and preventable treatments, as long as there are strategies for situational diagnosis and early interventions, in addition to measures to promote health and prevent these problems.
ART, designed to be used in places with no access to conventional procedures, is an essential and safe approach to the problems identified by the studies included in this review, as it can be performed in alternative social spaces, such as schools, in collective actions. It seems to have a lower cost than the conventional dental practice7. In addition, it is within the scope of minimal intervention dentistry, which focuses on maintaining oral health throughout the life cycle through preventive and minimally invasive care8,38.
Regarding the institutions, there were government structures reported in most countries, with their ministries of health or local coordination in the formulation stage. However, while the studies cite the presence of institutions, few describe their role in decision making and planning for implementation. In addition, few studies have reported on networks and political legacies. Therefore, little is known about the intrinsic characteristics of public oral health programs or policies in which ART is inserted as a routine health service.
Regarding ideas, although all studies reported the influence of scientific evidence or the knowledge of researchers, the type of evidence used is unclear. Still, conceptual use seems to have occurred generally (to provide a general understanding of a given topic), rather than instrumentally (with specific intentions of using scientific evidence to solve well-defined problems)39. It is worth highlighting that since the 1990s the WHO has widely disseminated the results of research through the production of materials that translated the scientific evidence produced5,40, as an important external inducer of the use of ART, having been reported in all experiments.
The instrumental use of scientific evidence can contribute to developing more solid and sustainable policies in the long term. Still, there are several reasons for underuse, such as 1. The evidence competes with other factors in the policy-making process; 2. the evidence is not valued; 3. the evidence is not relevant; 4. the evidence is not easy to use (the results were not effectively communicated or were not available when decision makers needed it, and 5. decision makers do not have mechanisms to facilitate the use of evidence)41,43.
Finally, in all countries, there were reports of interest by researchers and politicians. However, there is also a lack of information about the role of these actors in decision making processes. Bolivia was the only country where the presence of social groups, such as schoolteachers and the children’s families, were reported in relation to the implementation of ART as an intersectoral policy, with health education, supervised toothbrushing, and restorative treatments in the school environment18. This seems to explain the weakness observed in most ART implementations as a policy. That is, as research related to the instrumental use of evidence for well-informed decision making argues for the participation of representatives of all actors involved in this process, as happens, for example, in deliberative dialog and the synthesizing of scientific evidence, which offer feasible political options for facing well-defined problems43.
All countries increased access to health services after implementation15,24,28, especially in municipalities with a low human development index (HDI), as in the case of Mexico23,24, or in rural or remote areas, as in Bolivia30. However, although the treatment was designed to be conducted in territories where there was no access to conventional treatment, in countries where studies were conducted to evaluate the quality and longevity of restorations, such as Mexico24 and Zimbabwe31–33, results were close to those of systematic reviews involving controlled clinical trials.
The survival rates were very high, which indicates that ART, if correctly indicated and performed, can be routine in health services, regardless of electricity, HDI, or location. It is worth mentioning that the criteria used in the included studies evaluated the presence of complete restoration or wear that did not require repair, but in the context of large-scale implantation, the presence of restorative material with failures that need repair can be considered a success, if there is no active caries lesion or recurrence. In addition, in cases of fracture or total loss of the restoration, if the carious lesion is paralyzed, it can also be a positive result because more invasive treatments are avoided. However, only follow-ups of occlusal cavities were performed by the researchers and in only two countries23,24,31−33. The difficulty of monitoring patients in routine care is understood, especially in the context of implementation, in which professionals are still adapting to new practices. Still, efforts are needed to include the monitoring of procedures performed on teeth with one or more tooth surfaces injured as routine in health services.
Regarding the barriers identified in the implementation, the lack of supplies (dental instruments and restorative materials) to perform the procedures and induction by the service managers (through stipulation of targets, monitoring, financial resources) seems to have more influence than the other barriers mentioned.
One of the studies conducted in Cambodia20 pointed out that after years of offering well-structured courses to train dental nurses who would work in remote provinces in the country, little was done concerning restorative treatments. During the execution of the research, a health unit received the necessary inputs, received quarterly visits by members of the Ministry of Health, and goals were agreed upon. At the same time, there was no interference in the other, which resulted in a significant increase in minimally invasive restorative treatments in this unit. Therefore, it seems that permanent education alone, although fundamental for updating and changing professionals’ perceptions, is not enough for new practices to be established. Political instability, lack of support in institutions, and lack of engaged and participative leadership were identified as determining factors in cases where ART was not consolidated as a sustainable public policy28.
In addition to the common barriers reported, it is worth highlighting an important finding in a study conducted in Bolivia, as information related to the dosage of components of glass ionomer cement for handling under extreme environmental conditions is not described in detail in technical profiles of manufacturers (in the case of Bolivia, altitudes well above sea level and relative air humidity ranging from 20% to more than 90%). This can be related to obtaining an adequate viscosity, resistance, and adherence of the products, which can negatively impact the quality of the results18. In the case of Bolivia, the material handling protocols were defined based on a consensus with a committee of experts.
As for the facilitators, the findings show that permanent education and professional practice enhance the use of ART as routine practice in health services and the availability of inputs and induction by managers, as already discussed. In addition, regarding service users, there seems to be high satisfaction with the approach and reduction of fear/anxiety in dental treatments18. The scientific literature corroborates these findings since the first clinical studies with ART reported greater comfort and acceptance of patients, especially children, as they do not receive dental anesthesia, rubber dam isolation, and use of bur. Another factor that contributes to acceptance is the possibility of performing treatments in schools, where children are, in general, less anxious than those treated in clinics or dental offices8.
Despite the high performance of the technique, that has been scientifically proven over the last decades, the implementation of ART as a policy has only been identified in developing countries, that are in most cases without universal health systems. Therefore, it was not possible to evaluate its implementation in better structured healthcare systems, which could guarantee conditions for the sustainability of ART with less structural difficulties.
Finally, at the beginning of 2020, the WHO declared the spread of COVID-19 to be pandemic. The COVID-19 has had a particular impact on dentistry. Studies indicate sites of the oral cavity as possible entries of the coronavirus and that angiotensin receptors present in salivary gland ducts can be the primary target of pathogenic cellular invasion44,45. Moreover, as may dental procedures generate aerosols, such procedures and practices are being reconsidered. Faced with this scenario, aggravated by the scarcity of personal protective equipment, lack of clear biosafety protocols, the need to preserve health teams and reduce risks of contamination by users, health systems around the world initially suspended elective procedures in dentistry, with urgent and emergency maintenance only, as recommended by several institutions and local governments46–50.
In this context, Minimal Intervention Dentistry deserves even more attention from researchers, health service managers, and policymakers. It enables other types of health care that are not restricted to operative procedures38. In addition, non-generating aerosol procedures, such as ART, are necessary for the resumption of oral health in the trans and post-pandemic periods. New policies and programs must be well-structured for developing and implementing ART in routine dental care.