title: Factors inhibiting the implementation of the Atraumatic Restorative Treatment approach in public oral health services in Gauteng Province, South Africa.
abstract: OBJECTIVE
  To investigate potential barriers to the utilisation of the ART approach in a South African public oral health service.
  
  
  METHODS
  7 barriers were identified: patient load/work load, operator opinion, patient opinion, service management, material supply, clinical ART skill, chair-side assistance. Operators were asked to answer a questionnaire one year after completing the ART training. Responses ranged from 1 = no barrier to 5 = highest barrier. Treatment data per operator were collected during 1 year after training, for both dentitions, including: number of extracted teeth, placed traditional restorations, ART restorations. The restoration/extraction (REX) ratio and the proportion of ART restorations (ART%) of the total number of restorations were calculated and correlated with the barrier variables. Pearson correlation, ANOVA and 2-tailed t-tests were used in the statistical analyses.
  
  
  RESULTS
  Patient load/work load (mean = 2.80: SE = 0.16) was the strongest barrier (p<0.001) and clinical ART skill was the weakest barrier (p<0.001). A significant correlation between material supply and mean REX score was observed in both dentitions. In primary teeth, the ART% correlated significantly with clinical ART skill (r= -0.63; p<0.01). In permanent teeth, statistically significant correlations were observed between ART% and patient load/work load (r = -0.54; p<0.05), patient opinion (r = -0.76; p<0.01), operator opinion (r = -0.53; p<0.05), chair-side assistance (r = -0.57; p<0.05), oral health service management (r = -0.46; p<0.05).
  
  
  CONCLUSIONS
  1 year after ART training completion high patient load/work load, followed by insufficient provision of materials/instruments, were the two most inhibiting barriers to the use of ART in the public oral health services. Dentists' perceptions of low clinical skill levels in performing ART confidently inhibited the use of ART in primary teeth in children.
authors.affiliation: Division of Public Oral Health, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Steffen
authors.initials: S
authors.lastname: Mickenautsch
authors.forename: Jo E
authors.initials: JE
authors.lastname: Frencken
authors.forename: Martin
authors.initials: M
authors.lastname: Van't Hof