• The mitral valve apparatus is a funnel-shaped structure with its apex beat on the left ventricle.
• Mitral Stenosis is the narrowing of the mitral valve of the heart.
• Leads to complications due to the impairment of blood flow
• More commonly seen in females.
• Most Common cause : Rheumatic Heart Disease.

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ALTERED ANATOMY IN RHEUMATIC MITRAL STENOSIS

1. Primary Pathologic Features:
   • Thickened mitral cusps with/without calcification.
   • Fusion of valve commissures.
   • Shortening & fusion of chordae tendineae.
2. Secondary Pathological Features:
   • Left atrial hypertrophy & dilatation.
   • Left atrial thrombi.
   • Changes in venous & arterial hypertension in pulmonary vasculature.

ETIOLOGY:
• Rheumatic fever.
• Congenital mitral Stenosis
• Systemic Lupus Erythematosus (SLE)
• Malignant carcinoid
• Gout
• Atrial Myxoma
• Infective Endocarditis (rare)
• Rheumatoid Arthritis (rare)

PATHOPHYSIOLOGY:

CLINICAL FEATURES:
• Early presentation of Mitral stenosis include breathlessness on exertion and fatigue.
• As stenosis progresses, patients are dyspnic on rest.
• They have orthopnoea & paroxysmal nocturnal dyspnoea.
• Acute pulmonary oedema may occur.
• Haemoptysis: due to rupture of pulmonary-bronchial connection.
• Edema of lower limbs.
• Thromoembolic events like stroke, limb ischaemia
• Winter bronchitis: Patient with myocardial infarction are prone to recurrent attacks of bronchitis, particularly during winters.

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INVESTIGATIONS:

• ECG: May indicate left atrial(LA) enlargement, right ventricular hypertrophy and atrial fibrillation.
• CHEST X-RAY: LA enlargement, pulmonary congestion.
• ECHOCARDIOGRAPHY: Most sensitive & specific non-invasive methods to diagnose valvular disease.

• May reveal structural abnormalities of the valve.
• Size of cardiac chambers.
• Pulmonary artery pressure.
• Ventricular dysfunction & presence of thrombi.

CARDIAC CATHETERIZATION: Used to assess associated valvular lesions & to detect coronary artery disease.

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MANAGEMENT:

1. Treatment of atrial afibrillation

-Anticoagulants. – Verapamil. -Digoxin. – Beta blockers.

2. Treatment right ventricular failure:

• Salt restrictions.
• Diuretics
• Digoxin.

3. Restriction of physical activity.

4. Prophylaxis should be given to all patients to prevent rheumatic fever.

5. Prophylaxis for Infective Endocarditis should be given prior to the procedure.

SURGICAL MANAGEMENT:

1. MITRAL VALVECTOMY

Percutaneous Balloon Valvotomy:

• Indicated when mitral valve is non-calcified &without regurgitation.
• Procedure involves passing of a catheter across the valve & inflation of the balloon to dilate the orifice.

Open Valvotomy:

• Carried out in patients where balloon valvotomy is not possible or in cases with restenosis(*means that a section of blocked artery that was opened up with angioplasty or a stent has become narrowed again)
• In this procedure, the fusion of the valve is loosened, Ca(calcium) deposits and thrombi are removed.

2. MITRAL VALVE REPLACEMENT:
o Mitral Valve is replaced when there is critical mitral stenosis(<1cm² of orifice size)
o And/or there is an associated significant mitral regurgitation.
o Replacement done,when mitral valve is severely distorted & calcified.

COMPLICATIONS:
o Atrial fibrillation
o Pulmonary Hypertension
o Right Ventricular Failure
o Systemic thromboembolism
o Winter Bronchitis
o Ortner’s Syndrome

REFERENCES:

• Davidson’s Principle and Practise of Medicine
• Medicine Prep Manual for Undergraduate, K George Mathew(4th Edition)
• Mayoclinic.org
• Medlineplus.gov
• Medmovie.com

• ART :Is defined as a minimally invasive care approach in preventing dental caries and stopping its further progression. (Jo E. Frencken, 2012)
• It consists of two components: sealing caries prone pits and fissures and restoring cavitated dentine lesions with sealant restorations.
• American Academy of paediatric Dentistry (AAPD) defines ART as “a dental caries treatment procedure involving the removal of soft, demineralized tooth tissue using hand instrument alone, followed by restoration of the tooth with an adhesive restorative material, routinely glass ionomer”.
• ART may be used to restore and prevent caries in young patients, uncooperative patients, or patients with special health care needs or when traditional cavity preparation and/or placement of traditional dental restorations are not feasible.
• ART is based on modern knowledge about minimal intervention, minimal invasion and minimal cavity preparation for carious lesions.
• It is a procedure based removing carious tooth tissues using hand instruments alone and restoring the cavity with an adhesive restorative material.

PRINCIPLES:
The two main principles of ART are:

1. Removing carious tooth tissues using hand instruments only
2. Restoring the cavity with a restorative material that sticks to the tooth.
   The reasons for using hand instruments rather than electric rotating handpiecesare:

• The use of a biological approach, which requires minimal cavity preparation that conserves sound tooth tissues and causes less trauma to the teeth.
• The low cost of hand instruments compared to electrically driven dental equipment,
• The limited of pain that reduces the need for local anesthesia to a minimum and reduces psychological trauma to patients,
• Simplified infection control. Hand instruments can easily be cleaned and sterilized after every patient.

Currently ART is performed using glass ionomer as the restorative material.
The reasons for using glass ionomer are:
• The Glass-ionomer sticks chemically to both enamel and dentine, the need to cut sound tooth tissue to prepare the cavity is reduced,
• Fluoride is released from the restoration which will prevent and arrest caries and
• It is rather similar to hard oral tissues and does not inflame the pulp or and does not inflame the pulp or gingiva

INDICATIONS:
ART is carried out :
• Only in small cavities (involving dentin).
• In those cavities that are accessible to hand instruments.
• Public Health programs
• In cases when routine dental treatment cannot be performed because of a lack of facilities or accessibility to a dental clinic.
• Can be used in schools as a community measure to control caries in a large number of children.
• Can be used in both primary and permanent teeth.

CONTRAINDICATIONS:
• There is presence of swelling (abscess) or fistula (opening from abscess to the oral cavity) near the carious tooth.
• The pulp of the tooth is exposed.
• Teeth have been painful for a long time and there may be chronic
• Inflammation of the pulp,
• There is an obvious carious cavity,but the opening is inaccessible to hand instruments
• There are clear signs of a cavity, for example in a proximal surface, but the cavity cannot be entered from the proximal or the occlusal direction.

ADVANTAGES:
• ART is a biological approach that requires minimal cavity preparation
• It conserves sound tooth tissues and causes less trauma to teeth
• As ART is painless the need for local anesthetics are reduced and so is the psychological trauma to patients.
• Simplifies infection control as hand instruments can easily be cleaned and sterilized.
• No electrically driven and expensive dental equipment needed which enables ART to be practiced in remote areas and in the field.
• This technique is simple enough to train to train non- dental personnel or primary health care workers.
• It is very cost effective.
• As it is a friendly procedure, there great potentials for its use among children, fearful adults, physically and mentally handicapped and the elderly.
• Makes restorable care more accessible for all the population groups.

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MATERIALS:
• ART is a treatment strategy that requires trained personnel and suitable materials for its success
• ART is best performed using glass ionomer cement (GIC).
• GIC (such as Fuji IX,GC Int) is a glass polyalkenoate cement that consists of calcium or strontium alumino-fluoro-silicate glass powder and water-soluble polymer.
• Several factors led to the selection of GIC as a suitable material for ART.
• These factors included its fluoride-releasing properties, its ability to bond to enamel and dentine, its pulpal biocompatibility, and its ease of manipulation.
• The fluoride-release from GIC seems to be advantageous for ART Fluoride that is released from GIC makes the tooth structures (enamel and dentine) more resistant to acidic invasion by bacteria.
• Fluoride can be released from glass ionomers for up to five years.
• In addition, GIC acts as a reservoir for fluoride, as it takes up fluoride ions from topical fluoride This property of GIC means that the teeth treated with ART remain les susceptible to caries for long periods.
A glass ionomer that in specifically designed for ART is available, which is termed a high-viscocity glass ionomer (such as Ketac Molar Easymix, 3M ESPE, Seefeld, Germany).
It possesses a high powder-to-liquid ratio, with improved mechanical properties, including wear resistance, compressive strength, and marginal adaptability.
A high-viscosity glass ionomer is the recommended type of glass ionomer for ART. A high viscosity glass ionomer is more durable than a low or medium-viscosity glass ionomer. Furthermore, a study performed in 2006 suggested that medium-viscosity glass ionomers should not be used in ART.

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• 

SUCCESS RATE :

1. In 2001, a study was conducted in China regarding the success rate of ART performed on the primary teeth in various cavity designs 146). They found that, in 30 months of follow-up, the success rates were high for Class I and Class V restorations (79% and 70%, respectively). For Class II restorations, the success rate was found to be moderate. However, the success rates for both Class II and Class IV were found to be low .
2. Another study was performed in 2003 that showed that, in 24 months of follow-up, the success rate of ART performed in Class I cavities was high (89.6%). They also concluded that there was no significant difference in the success rate between ART and amalgam performed in Class I Cavities.
3. A meta-analysis was conducted in 2006 which addressed the success rates of ART in primary and permanent dentition. It concluded that, in 12 months of follow-up, the success rates of ART. made in the surfaces of single tooth and performed using high viscosity glass ionomer, were 95% and 97% for primary and permanent teeth, respectively.
4. Recently, a study was conducted in India addressing the success rate of ATR applied to one or two surfaces. They found that the success rate of ART was comparable to that of composite resins in 12 months of follow-up (89.7% for one surface and 88% for two surface restorations).
5. Regarding the method of the application of GIC in ART, a study was carried out in Brazil in 2016 which addressed the success rate of ART performed using a bilayer method 51. It concluded that the bilayer technique of ART increased the survival rate of proximal restorations in primary molars.

CONCLUSIONS:
• Based on the available literature, we conclude that ATR is a suitable treatment approach for the management of dental caries in several conditions in both primary and permanent teeth.
• ATR is used in cases where there are obstacles to reaching the dental care units
• A high-viscosity glass ionomer performed better than low and medium-viscosity glass ionomers in ART.
• Combining GIC with conditioner, as well as the use of the chemo-mechanical approach, improved the success rate of ART.
• ATR is an acceptable strategy, with success rates comparable to the traditional treatment methods.
REFERENCES:
• Essentials of Public Health Dentistry, Soben Peter(6th Edition).
• Atraumatic Restorative Treatment and Interim Therapeutic Restoration: A Review of the Literature(Dentist Journal).
• Textbook of Preventive and Community Dentistry, Joseph John (3rd Edition).