studies on these and other skin barrier creams and their effects on the permeability o f human skin in the presence o f other deleteri­ ous compounds are therefore warranted. Acknowledgements We gratefully acknowledge the University o f Stellenbosch and the Medical Research Council, for their financial support. We wish also to thank M rs C de Beer, Department o f Dermatology, for obtaining the skin samples. REFERENCES Baur X, Chen Z, Allmers H & Raulf Heimsoth M (1998). Results of wearing test with two different latex gloves with and without the use o f skin-protection cream. Allergy; 53: 441-444. Beezhold DH, Kostyal DA & Wiseman J (1994). The transfer o f protein allergens from latex gloves. AORNJ; 59: 605-613. Boman A, Wahlberg JE ft Johansson G (1982). A method for the study of the effect of barrier creams and protective gloves on the percutaneous absorption o f solvents. Dermatologica; 164: 157-160. Cooper ER (1984). Increased skin permeability o f lipophilic molecules. Journal o f Pharmaceutical Sciences; 73: 1153-1156. Frantz TJ (1975). Percutaneous absorption. On the relevance o f in vitro data. Journal o f Investigative Dermatology; 64: 190-195. Galey WR, Lonsdale HK & Nacht S (1976). The in vitro permeability of skin and buccal mucosa to selected drugs and tritiated water. Journal o f Investigative Dermatology, 67: 713-717. Grevelink SA, Murrell DF & Olsen EA (1992). Effectiveness of various barrier prepara­ tions in preventing and/or ameliorating experimentally produced Toxicodendron dermatitis. Journal o f the American Academy o f Dermatology; 27: 182-188. Harrison SM, Barry BW ft Dugard PH (1984). Effects of freezing on human skin perme­ ability. Journal o f Pharmacy and Pharmacology; 36: 261-262. Jennrich R1 ft Schluchter M D (1986). Unbalanced repeated measures models with struc­ tured covariance matrices. Biometrics; 42: 805-820. Marks R, Dykes PJ & Hamami 1 (1989). Two novel techniques for the evaluation of bar­ rier creams. British Journal o f Dermatology; 120: 655-660. Swarbrick J, Lee G & Brom J (1982). Drug permeation through human skin. 1. Effect of storage conditions of skin. Journal o f Investigative Dermatology; 78: 63-66. Treffel P, Gabard B & Juch R (1994). Evaluation of barrier creams: an in vitro technique on human skin. Acta Dermato-Venereologica; 74: 7-11. Van der Bijl P, Thompson IOC & Squier CA (1997) Comparative permeability of human vaginal and buccal mucosa to water. European Journal o f Oral Sciences; 105: 571-575. Van der Bijl P ft Van Eyk AD (1999). Penetration of benzo[a]pyrene through human buccal and vaginal mucosa. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontics; 87: 452-455. Van der Bijl P, Van Eyk AD, Cilliers J & Stander 1A (2000). Diffusion of water across human skin in the presence of two barrier creams. Skin Pharmacology and Applied Skin Physiology; 13: 104-110. Van der Bijl P, Van Eyk AD ft Thompson IOC (1998). Permeation o f 176-estradiol through human vaginal and buccal mucosa. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endo; 85: 393-398. Wahlberg JE (1972). Anti-chromium barrier creams. Dermatologica; 145: 175-181. Wigger-Alberti W, Rougier A, Richard A & Eisner P (1998). Efficacy of protective creams in a modified repeated irritation test. Acta Dermato-Venereologica (Stockholm); 78: 270- 273. S Mickenautsch, I Munshi, ES Grossm an O R IG IN A L R E S E A R C H PA PERS Comparative cost of ART and conventional treatment within a dental school clinic SUMMARY Background: The changing oral health needs in South Africa require that both the teaching and clinical techniques o f atraumatic restorative treatment (ART) form a part o f the restorative undergraduate curriculum. Objective: This study was undertaken to establish and compare the estimated costing o f an amalgam, composite resin and A RT restoration within the Board o f Health Funders (BHF) rec­ ommended scale o f benefits at the School o f Oral Health Sciences Oral and Dental Hospital, University o f the Witwatersrand (SOHS). Methods: Fixed and variable costs were calculated by pricing items and equipment used in each procedure. The output values were established according to the recommended scale o f benefits (BHF, 1999). This enabled the calculation o f contribution mar­ gins and net income for each o f the three restorations. Results: The annual capital cost for the A RT approach is approximately 50°/o o f the other two options (e.g. per multiple surface restoration A RT= R1.58; amalgam and composite resin restorative procedures: R3.12 and R3.10 respectively), despite the fact that A RT restorations are rendered in a modern dental setting. Conclusions: Our study shows that implementation o f the ART approach within the clinic setting o f the SO H S can be accom­ plished without additional cost. Furthermore ART can be per­ formed as an economically viable alternative to conventional treatment procedures within the clinic setting. The study rep­ resents a first step towards determining the cost efficiency of implementing ART as a pragmatic and cost-effective restora­ tive option within the SOHS, University o f the Witwatersrand. S A fr Dent J 2002; 57: 52 -58 S Mickenautsch, BDS* I Munshi, MDent** ES Grossman, PhD*** Dentist Supervisor, Division of Public Oral Health* Senior Specialist, Division of Restorative Dentistry** and Specialist Scientist, Dental Research Institute M R C IW its***, School of Oral Health Sciences, Faculty of Health Sciences, University o f the Witwatersrand Corresponding author: D r ES Grossman, Dental Research Institute. Private Bag 3, W ITS 2050, South Africa. Tel: + 2 7 I I 717-2137, fax:+ 2 7 I I 717-2121, e-mail: 078 e sg@ ch iro n .w it s.a c .za Introduction Atraumatic restorative treatment (ART) has been successfully used as a tooth restoration approach in rural areas where electricity is absent, treatment facilities are non-existent or where funds do not allow conventional dentistry.' ART is currently being used in the peri-urban region o f Johannesburg via a mobile dental unit2 and within the public oral health services o f Gauteng, North West and KwaZulu-Natal provinces. While ART may be regarded by the devel­ oped worid as a palliative option exclusively for developing world F E B R U A R Y 2002 V O L . 57 N O . 2 S A D j mailto:078esg@chiron.wits.ac.za populations there is growing interest in the use of ART as an alter­ native method of treating patients where restorative care is difficult or impossible to provide.5 These are patients with contraindications for local anaesthesia, housebound ot institutionalised persons, fear­ ful children, those in urgent need o f dental care whose health situa­ tion contraindicates dental treatment. ART is also promoted as an adjunct to conventional dental care within the clinic setting. This is in cases of early childhood caries in toddlers or as a means o f intro­ ducing a child to the restorative experience.3 The current emphasis in South Africa on the primary health care approach4 requires that ART be included in the restorative undergraduate curriculum. The initiation of the post-BDS community service programme in 2000 by the Department o f Health in communities deprived of oral health care has brought further urgency to the teaching and implementa­ tion o f the ART approach. Finally, the financial constraints under which oral health services in South Africa operate make it imperative to critically evaluate the ART approach as an economic alternative in special cases to conventional treatment procedures within the clinic setting. This study was undertaken to establish and compare the estimated costing of an amalgam, composite resin and ART restoration within the costing framework of the School o f Oral Health Sciences (SOHS), University o f the Witwatersrand as a first step towards determining the cost-efficiency o f implementing ART as a pragmatic and eco­ nomic restorative option within the Division o f Restorative Dentistry. Method The model used for this comparative cost analysis o f restoring a sin­ gle and a multiple surface cavity using amalgam, composite resin and ART was based on a study which evaluated a public services mobile dental surgery.5 Tbe following components were considered and defined5 as follows. Capital costs: all equipment and instru­ mentation, linked to depreciation, used in each restorative proce­ dure. Variable costs: consumables used in each procedure. Fixed costs: according to the model, fixed costs are computed as capital cost as well as the salary equivalent for time spent on the proce­ dure. In this study we excluded a dentist’s salary from our calcula­ tions as the services at the SOHS are rendered try unpaid students. Thus fixed costs are calculated using capital costs only. Output value: the benefit value set by the Board o f Health Funders (BHF), formerly the Representative Association o f Medical Schemes, was used to represent the total income. Contribution m argin: the total income less the variable cost. Net income: the contribution margin less fixed cost. All items used in the restoration procedures were listed and prices Table I A. Capital cost of one amalgam restoration N Item (all Q ty Estimated Purchase Capital manufactured depreciation price in per year in year 2000) (in years) Rand in Rand Single surface 01. Fast handpiece 1 5 2 500.00 500.00 02. Slow handpiece 1 5 3 000.00 600.00 03. Mixing spatula 1 5 150.00 30.00 04. Amalgamator 1 5 6 000.00 1 200.00 05. Amalgam rest dispenser 1 5 150.00 30.00 06. Dappen dish 1 5 200.00 40.00 07. Syringe 1 5 200.00 40.00 08. Diamond bur 1 2 12.00 6.00 09. Steel bur 1 2 12.50 6.25 10. Amalgam applicator 1 5 150.00 30.00 II. Plugger 1 5 150.00 30.00 12. Carver 1 5 150.00 30.00 13. Dental chair 1 5 28 750.00 5 750.00 14. Suction unit 1 5 10 100.00 2 020.00 15. Dental unit 1 5 15 000.00 3 000.00 16. Autoclave 1 5 14 500.00 2 900.00 17. Mouth mirror 1 5 150.00 30.00 18. Dental probe 1 5 150.00 30.00 20. Dental tweezers 1 5 150.00 30.00 Total per annum 16 302.25 Total per month 1 358.52 Total per day 67.93 Total per hour 8.49 Total per minute 0.14 Total per restoration (22 min) 3.11 Multiple surface 10. Matrix retainer 1 5 150.00 30.00 Total per annum 16 332.25 Total per month 1 361.02 Total per day 68.05 Total per hour 8.51 Total per minute 0.14 Total per restoration (22 min) 3.12 I month = 20 working days; I working day = 8 hours. S A D J F E B R U A R Y 2002 V O L . 57 N O . 2 Table I B. Variable costs of one amalgam restoration N Item Quantity Quantity Price per Price per needed per pack pack in Rand quantity needed in Rand Single surface 01. Amalgam caps. 1 100 200.00 2.00 02. Articulating paper 1 sheet 100 150.00 1.50 03. Cotton wool rolls 4 100 150.00 6.00 04. Gauze 2 pads 100 25.00 0.50 05. Lining cement 1 100 300.00 3.00 06. Local anaesthetic cart 1 100 250.00 2.50 07. Injection needle 1 100 50.00 0.50 08. Mouth mask 1 100 60.00 0.60 09. Gloves 1 pair 50 pairs 30.00 0.60 10. Hibiscrub (hand disinfectant) 5 ml 500 ml 40.00 0.50 11. Ultra swipes (surface disinf.) 1 wipe 160 wipes 165.00 1.03 Total per restoration 18.73 Multiple surface 3. Matrix band 1 12 20.00 1.67 4. Wedges 2 100 65.00 0.65 Total per restoration 2 1 .OS Table IC Income statements for I x amalgam restoration (SOHS) Single surface 1. Output value R 77.00 2. Variable cost R 18.73 3. Contribution margin R 58.27 4. Fixed costs R 3.11 4.1. Salary R 0.00 4.2. Capital cost R 3.11 5. Net income R 55.16 Multiple surface 1. Output value R 96.20 2. Variable cost R 21.05 3. Contribution margin R 75.15 4. Fixed costs R 3.12 4.1. Salary R 0.00 4.2. Capital cost R 3.12 5. Net income R 72.03 * Net income as a percentage of output value. *71.6% *74.8% obtained from the price lists o f the Central Stores, SOHS, University o f the Witwatersrand; Milners (PO Box 30721, Kyalami 1684); The Dental Warehouse (Private Bag X I, Highlands North 2037) and Adcoek-lngram (Private Bag 69, Bryanston 2021). Commercial prices were those in force on 1 March 2000. For Central Stores the average prices paid over a period o f 2 years was used. The price of the glass ionomer used in Table 111B is that for Ketac Molar Liquid+Powder (handmix) (ESPE, Dental Medizin, Germany supplied by The Dental Warehouse). Prices and volumes o f material were resolved to calculate the cost o f the consumable per restoration. The costs o f white coats, water and electricity supply were excluded. While it is known that less water and electricity are used during an ART procedure the difficulties in establishing the exact amount o f water or current units actuated per restoration make costing for these unfeasible. The depredation of dental equipment was according to write-off periods laid down by the South African Revenue Services6 with an assumed year o f manu­ facture of 2000 in all eases. The following BHF codes were used for each restoration type and the costs attached to each incorporated within the estimate. Am algam restoration: Output value: single surface restoration: BHF 1999 code 8341; two surface restoration: BHF 1999 code 8342. Composite resin restoration: Output value: single surface posterior restoration: BH F 1999 code 8367; two surface posterior restoration: BHF 1999 code 8368. A R T restoration: Up to the pre­ sent there has been no BHF code assigned for the provision o f ART by the Board o f Health Funders. However international research has shown that the survival rates o f ART restorations are comparable with amalgam under similar field conditions.7 Therefore the BHF values for amalgam were used in order to set the output values for ART. Results Tables 1 A, B and C, respectively, list the charges attached to the capital costs, variable costs and income statement for an amalgam restoration. Composite resin and ART restoration charges are similar­ ly shown in Tables 11 A-C and Tables 111 A-C, respectively. The results show a slight difference between the annual capital cost for dental equipment used for amalgam and composite restorations. This adds to R16 202.25 for single surface composite resin restoration and R16 302.25 for a single surface amalgam. Multiple surface restora­ tions are marginally more costly at R16 232.25 and R16 332.25 for each material respectively. In marked contrast, annual capital costs for dental equipment used for ART restorations (R8 950.00 for sin­ gle surface and R8 980.00 for multiple surface) are about 50°/o cheaper than for conventional restorative procedures. This is against the background o f ART procedures rendered in a modem dental clinic. The lower annual capital costs are due to the inexpensive hand instruments used in the approach and the absence o f costly items such as hand pieces, suction unit, amalgamator and curing light. The total capital costs per restoration similarly show that by comparison a single surface ART restoration costs 50°/o less at R1.58 than amalgam and composite resin restoration (R3.11 and R3.09 respectively). F E B R U A R Y 2002 V O L . 57 N O . 2 S A D J Variable costs of R33.79 for a multiple surface composite resin restoration make this the most expensive treatment in this study. A multiple surface amalgam restoration is costed at R21.05 with ART being R19.60. The restorative material itself is the main determinant o f size o f the variable cost, amalgam costing R2.00, composite resin at R5.00 and trie glass ionomer cement for ART being R6.34 per single surface. The fewer and cheaper items used in the ART approach counter the more expensive glass ionomer cement (Tables 1-111B). We assumed the output value for ART to be the same as amalgam restorations according to BHF recommendations. For a single sur­ face this is R77.00 and multiple surface is R96.20. A composite resin restoration is set at R91.00 and R 112.00 respectively. Fixed costs for using each of the restorative materials are virtually identical for sin­ gle and multiple surface restorations. The addition of variable costs to the costing structure produced a net income for a single surface ART restoration of R58.14 (75.5 % o f output value); R55.16 (71.6 °/o) for an amalgam restoration and R56.44 (62.0 % ) for composite resin restorations (Tables 1-111C). The components of total income per restoration type are summarised in Fig. 1. Discussion This is a first study in which the cost o f ART and conventional restorative dentistry has been compared in the costing structure o f a modem dental school setting. Indeed to our knowledge no cost analysis has been published on any aspect of South African dental schools. The model for this study was based on that undertaken by Smit and Holtshousen,5 who analysed the cost efficiency of a public services mobile dental surgery. While the two study subjects are hardly comparable the investigative route appeared suitable in the absence o f any other similar endeavour. Our study shows that the ART approach can be cost-effectively implemented within the SOUS, University of the Witwatersrand. Furthermore ART can be practised as a viable economic alternative to conventional treatment procedures within the clinical setting. This is not only from a direct cost point o f view but with the added spin-off o f reduced mainte­ nance costs o f dental equipment which are not used in the ART approach. After much debate we decided to exclude salary per time o f proce­ dure from the total fixed costs o f the restorations. Students are responsible for the majority of the restoration work in the teaching clinics which were the site for evaluation. However, for completeness we include the following should there be a wish to undertake a Table 11 A. Capital cost of one composite restoration N Item Qty Year manufactured Estimated depreciation (in years) Purchase price in Rand Capital per year in Rand Single surface 01. Fast handpiece 1 2000 5 2 500.00 500.00 2. Slow handpiece 1 2000 5 3 000.00 600.00 03. Rubber dam 1 2000 5 150.00 30.00 04. Curing light 1 2000 5 6 000.00 1 200.00 05. Dental tweezers 1 2000 5 150.00 30.00 06. Dental probe 1 2000 5 150.00 30.00 07. Syringe 1 2000 5 200.00 40.00 08. Diamond bur 1 2000 2 12.00 6.00 09. Steel bur 1 2000 2 12.50 6.25 10. Mouth mirror 1 2000 5 150.00 30.00 II. Plugger 1 2000 5 150.00 30.00 12. Carver 1 2000 5 150.00 30.00 13. Dental chair 1 2000 5 28 750.00 5 750.00 14. Suction unit 1 2000 5 10 100.00 2 020.00 15. Dental unit 1 2000 5 15 000.00 3 000.00 16. Autoclave 1 2000 5 14 500.00 2 900.00 Total per annum 16 202.25 Total per month 1 350.18 Total per day 67.50 Total per hour 8.43 Total per minute 0.14 Total per restoration (22 min) 3.09 Multiple surface 10. Matrix retainer 1 2000 5 150.00 30.00 Total per annum 16 232.25 Total per month 1 352.69 Total per day 67.63 Total per hour 8.45 Total per minute 0.14 Total per restoration (22 min) 3.10 I month = 20 working days; I working day = 8 hours. S A D J F E B R U A R Y 2002 V O L .S 7 N O . 2 Table I IB. Variable costs of one composite restoration N Item Quantity needed Quantity per pack Price per pack in Rand Price per quantity needed in Rand Single surface 01. Composite ( Z 100) 1 100 500.00 5.00 02. Articulating paper 1 sheet 100 150.00 1.50 03. Cotton wool rolls 4 100 150.00 6.00 04. Gauze 2 pads 100 25.00 0.50 05. Lining cement (Vitrabond) 1 100 400.00 4.00 06. Local anaesthetic cart. 1 100 250.00 2.50 07. Injection needle 1 100 50.00 0.50 08. Mouth mask 1 100 60.00 0.60 09. Glove 1 pair 50 pairs 30.00 0.60 10. Hibiscrub (hand disinf.) 5 ml 500 ml 40.00 0.50 1 1. Ultra swipes (surface disinf.) 1 wipe 160 wipes 165.00 1.03 12. Scotchbond plus i 100 874.00 8.74 Total per restoration 31.47 Multiple surface 5. Matrix band i 12 20.00 1.67 6. Wedges 2 100 65.00 0.65 Total per restoration 33.79 Table IIC Income statement:for] x composite restoration (SOHS) Single surface 1 . Output value R 91.00 2. Variable cost R 31.47 3. Contribution margin R 59.53 4. Fixed costs R 3.09 4.1. Salary R 0.00 4.2. Capital cost R 3.09 5. Net income R 56.44 Multiple surface 1 . Output value R 112.00 2. Variable cost R 33.79 3. Contribution margin R 78.21 4. Fixed costs R 3.10 4.1. Salary R 0.00 4.2. Capital cost R 3.10 5. Net Income R 75.11 * Net income as a percentage of output value. similar comparison. Duration of procedure for one amalgam and one composite restoration is estimated as an average o f 22 minutes;’ ART restorations are estimated to take 19.8 minutes.9 According to this, the estimated price difference attached to the duration o f the restorative procedures is marginal and we feel that the inclusion o f a calculated salary per duration of procedure would have no significant impact on our findings. Other factors not related to the type of restoration, but rather to factors intrinsic to the treat­ ment, i.e. size o f cavity, location in the mouth and skills of the oper­ ator are major determinates of the length o f time needed per proce­ dure and are also not considered. A possible limitation of our study is the simplistic manner of our costing exercise. Paradoxically herein lies its greatest strength. We are aware that items such as service and maintenance costs o f dental equipment, as well as support staff salaries would certainly be incor­ porated into a more sophisticated economic exercise than this one. However this analysis pertains to the costing of the three treatment types within the clinic setting and Central Stores of the SOHS and such variables then remain standard. While a detailed breakdown of all factors impacting on the three dental restorative procedures stud­ ied, within the specifics of the SOHS, may not conclude with exactly the Rand costs o f our study, it will not affect the essential finding of the study, i.e. that ART is a cost-effective treatment within the clinic setting. The effort required to complete a more detailed task would cause the analysis to become grossly unwieldy and equally questionable. W e feel that the simplistic approach adopted in this study, in which we have selected items directly pertaining to the treatments as such, can be usefully applied in similar comparative studies. Finally we acknowledge that fees according to the scale o f benefits as determined by BH F are not charged at the SOHS. In the absence o f suitable alternatives we used the BHF fees as a more realistic value o f restorations rendered. The assumption that the output value o f an ART restoration equals amalgam can be debated. However, a final definition o f the exact output value o f an ART fill­ ing is only possible after the inclusion o f ART in the scale o f bene­ fits. The high net income reflected in our study is a reflection o f the sin­ gularity of our study environment (SOHS) and will certainly not be true for the private practitioner at large. The peculiarities intrinsic to a dental teaching hospital with its economic idiosyncrasies, curious subsidisation policies and conflicting teaching and service needs form a unique health and economic microcosm divorced from the private sector. Such a high net income is unrealistic and cannot be compared with the actualities encountered in the private sector and this must be noted. However the 50 °/o savings achieved on materi­ als and capital outlay will remain constant be it private practitioner or dental school clinic. Conclusion Economic analysis is used to help set priorities, predict outcomes, evaluate costs and consequences o f a course of action in dental health care. While the clinical effectiveness of ART has already been demonstrated,7 this study shows that ART is also a cost-effective means of oral health care within a modem dental clinic. The ART approach can be undertaken at approximately 50°/o o f the capital costs of conventional restorative dentistry within the SOHS. As such this finding would apply to all similar South African teaching dental F E B R U A R Y 2002 V O L . 57 N O . 2 S A D J Table III A. Capital costs of one ART restoration N Item Qty Year Estimated Purchase Capital manufactured depreciation price in per year (in years) Rand Rand Single surface 01. Excavator small 1 2000 5 150.00 30.00 02. Excavator medium 1 2000 5 150.00 30.00 03 Excavator large 1 2000 5 150.00 30.00 04. Hatchet/hoe 1 2000 5 150.00 30.00 05. Mixing spatula 1 2000 5 150.00 30.00 06. Plugger 1 2000 5 150.00 30.00 07. Carver 1 2000 5 150.00 30.00 08. Dental chair 1 2000 5 28 750.00 5 750.00 09. Autoclave 1 2000 5 14 500.00 2 900.00 10. Mouth mirror 1 2000 5 150.00 30.00 11. Dental probe 1 2000 5 150.00 30.00 12. Dental tweezers 1 2000 5 150.00 30.00 Total per annum 8 950.00 Total per month 745.83 Total per day 37.29 Total per hour 4.66 Total per minute 0.08 Total per restoration (22 min) 1.58 Multiple surface 10. Matrix retainer 1 2000 5 150.00 30.00 Total per annum 8 980.00 Total per month 748.33 Total per day 37.42 Total per hour 4.68 Total per minute 0.08 Total per restoration (22 min) 1.58 1 month = 20 working days; 1 working day = 8 hours. Table III B. Variable costs of one ART restoration N Item Quantity Quantity Price per Price per needed per pack pack in quantity needed Rand in Rand Single surface 01. Glass ionomer 180 mg 18 g 634.49 6.34 02. Vaseline 2 mg 50 g 5.00 0.01 03. Articulating pape 1 sheet 100 150.00 1.50 04. Cotton wool rolls 4 100 150.00 6.00 05. Cotton pellets 10 2 500 50.00 0.20 06. Gauze 2 pads 100 25.00 0.50 07. Mouth mask 1 100 60.00 0.60 08. Gloves 1 pair 50 pairs 30.00 0.60 09. Hibiscrub (hand disinf.) 5 ml 500 ml 40.00 0.50 10. Ultra swipes (surface disinf.) 1 wipe 160 wipes 165.00 1.03 Total per restoration 17.28 Multiple surface 7. Matrix band 1 12 20.00 1.67 8. Wedges 2 100 65.00 0.65 Total per restoration 19.60 S A D J F E B R U A R Y 2002 V O L . 57 N O . 2 Table III C Income statement:for I x ART restoration (SOHS) SA Rand Single surface 1. Output value R 77.00 2. Variable cost R 17.28 3. Contribution margin R 59.72 4. Fixed costs R 1.58 4.1. Salary R 0.00 4.2. Capital cost R 1.58 5. Net income R 58.14 Multiple surface 1. Output value R 96.20 2. Variable cost R 19.60 3. Contribution margin R 76.60 4. Fixed costs R 1.58 4.1. Salary R 0.00 4.2. Capital cost R 1.58 5. Net income R 75.02 * Net income as a percentage of output value. — *75,5 % Amalgam Capital cost g 3.09 3.11 1.58 Variable cost H 31.47 18.73 17.28 Net income □ 56.44 55.16 58.14 Amalgam 3.1 3.12 1.58 33.79 21.05 19.6 75.11 72.03 75.02 Fig. I. Components of total costs and income per restoration type in South African Rand for a single and multiple surface restoration. The figure at the top of each bar is the output *77.9 % value (BHF)- facilities. These findings suggest further reduced maintenance costs of dental equipment by using ART in the dental practice providing comprehensive dental care. This is the first study in which the cost o f ART and conventional restorative dentistry has been compared in the costing structure o f a clinic setting. REFERENCES 1. Frencken J, Phantumvanit P, Pilot T, Songpaisan Y, van Amerogen E. Manual for the Atraumatic Restorative Treatment Approach to Control Dental Caries. WHO Collaborating Centre for Oral Health Services Research, Groningen. Nijmegen, Netherlands: Benda Drukkers. 1997. 2. Mickenautsch S, Kopsala J, Rudolph MJ, Ogunbodede EO. Clinical evaluation of the ART approach and materials in peri-urban farm schools of the Johannesburg area. S Afr Dent J 2000; 55: 364-368. 3. Frencken J, Holmgren CJ. Atraumatic Restorative Treatment (ART) for Dental Caries. Nijmegen: STI Book bv, 1999. 4. Hobdell MH, Myburgh N. The needs of the population in relation to the training of oral health personnel and dental services. A paper presented at the Symposium ‘Changing the face of Dentistiy’ 7-8 April 1994, University of the Witwatersrand, Johannesburg. 5. Smit A, Holtshousen WSJ. Cost efficiency analysis o f a public services mobile dental surgery. Oral Health Auxilliaiy Training Division, School of Oral Health Sciences, University of the Witwatersrand, Johannesburg. 1999, Unpublished report. 6. Huxham K, Haupt P. Notes on South African Income Tax. Chapter 7: Capital allowance and recoupments. Constantia: H ft H Publications, 1998; 111-160. 7. Frencken J, Holmgren CJ. How effective is ART in the management o f dental caries? Community Dent Oral Epidemiol 1999; 27: 423-430. 8. Du Plessis JB, Carstens 1L, Rossouw LM, Olivier 1. The dental caries status o f the urban population in the major metropolitan areas of the Republic o f South Africa. In: Van Wyk PJ, ed. National Oral Health Survey: South Africa 1988/89. Pretoria: Department of Health, 1994: 24-32. 9. Frencken JE, Makoni F, Sithole WB. ART restorations and glass ionomer sealants in Zimbabwe: Survival after three years. Community Dent Oral Epidemiol 1998; 26: 372- 381. F E B R U A R Y 2002 V O L . 57 N O . 2 S A D j