|Year : 2022 | Volume
| Issue : 2 | Page : 112-117
A systematic review of randomized controlled trials on survival rate of atraumatic restorative treatment compared with conventional treatment on primary dentition
Harsha G Chaudhari1, Raju U Patil1, Prasad N Jathar1, Chirayu A Jain2
1 Department of Pediatric and Preventive Dentistry, STES Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Public Health Dentistry, STES Sinhgad Dental College and Hospital, Pune, Maharashtra, India
|Date of Submission||09-Mar-2022|
|Date of Decision||04-Jun-2022|
|Date of Acceptance||06-Jun-2022|
|Date of Web Publication||15-Jul-2022|
Dr. Harsha G Chaudhari
Department of Pediatric and Preventive Dentistry, STES Sinhgad Dental College and Hospital, S.No. 44/1 Vadgaon Bk, Pune - 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: In this COVID era, it's critical to promote nonaerosol procedures. Atraumatic restorative treatment (ART) is one of them, and it's particularly effective in children for lowering anxiety, enhancing dental health, and giving restorative care. Aim: The aim of this study was to assess the survival rate of ART compared with conventional treatment procedures in primary dentition. Materials and Methods: The review was done in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analysis statement and is been registered in PROSPERO (CRD42021213729). The studies included comprised clinical investigations with randomized controlled trials (RCTs) which compared the survival rate of ART and conventional restorative treatments using the same or different restorative materials to treat carious lesion. RCTs in which ART was compared with conventional treatment on patients in the age group of 6–10 years with minimum follow-up of 6 months. Studies available as open access and free full text in PubMed, DOAJ, and Google Scholar databases, and published in English Language only were included in the study. Cochrane's collaboration tool for RCTs was used for the assessment of risk of bias. Results: The survival rate of single surface and multiple surface in primary dentition treated according to the ART compared with conventional treatment was found to be similar. Conclusion: The ART approach is equally helpful in managing dental caries in children and this method may be considered a useful intervention in clinical practice to enhance the dental health of children.
Keywords: Atraumatic restorative treatment, conventional restorative treatments, deciduous teeth, or primary teeth
|How to cite this article:|
Chaudhari HG, Patil RU, Jathar PN, Jain CA. A systematic review of randomized controlled trials on survival rate of atraumatic restorative treatment compared with conventional treatment on primary dentition. J Indian Soc Pedod Prev Dent 2022;40:112-7
|How to cite this URL:|
Chaudhari HG, Patil RU, Jathar PN, Jain CA. A systematic review of randomized controlled trials on survival rate of atraumatic restorative treatment compared with conventional treatment on primary dentition. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Dec 3];40:112-7. Available from: http://www.jisppd.com/text.asp?2022/40/2/112/351036
| Introduction|| |
Aerosol minimization is critical in the current COVID scenario to prevent the virus from spreading. Because atraumatic restorative treatment (ART) is an aerosol-free therapy, it aids in the fight against the coronavirus and the successful management of dental cavities. Dental caries is the most frequent disease in the world and is considered the most serious oral health concern. Primary tooth restoration is part of a child's or adolescent's total oral health treatment plan, which should meet the child's functional and esthetic needs until tooth exfoliation. Rotary burs are used in traditional treatment methods (drill and fill), whereas ART uses solely hand devices.
ART is a minimally invasive procedure in which only decayed tissue is removed with hand instruments, usually without the use of anesthetic or electrically powered equipment, and the dental cavity is then restored with an adhesive filling material such as glass-ionomer cement (GIC), compomers, composite resins, or resin-modified GIC. Recently, modified ART approaches have been introduced, as opposed to “true” ART as described above. The modified approaches involve drilling, cleaning, restoring, and finishing with hand instruments, or using alternative restorative materials including amalgam. Apart from these modified approaches, the interim therapeutic restorations (ITR) approach was introduced by the American Academy of Pediatric Dentistry (AAPD) (AAPD 2008–2009), which uses similar technique as ART, although it may target different therapeutic goals. The ITR is opposite to the ART procedure, which involves the use of hand or slow-speed rotary instruments for the removal of caries, which uses only hand instruments, followed by restoration with an adhesive restorative material such as GIC. While ART is recognized as a permanent treatment, the AAPD regards ITR as a provisional technique. According to AAPD, it can then be considered a “true” ART, if ITR is applied using hand instruments, and not rotary instruments. A simplified and modified atraumatic restorative treatment (SMART) is a method to remove caries and minimal cavity preparation using only hand instruments and filling it with GIC, can be utilized to restore primary teeth. Silver diamine fluoride (SDF) can also be used in amalgamation with ART. In Silver Modified Atraumatic Restorative Technique (SMART) conventional GIC can be placed immediately after SDF.
Previously, studies have been published comparing ART with amalgam restorations in permanent as well as primary teeth, mainly in single-surface cavities. In most of the studies for previous reviews, ART restorations were not compared with conventional techniques (drilling and restoring and/or hand excavation associated with resin composite, amalgam, or compomer).
To the best of our knowledge, no systematic review was conducted to investigate the survival rate of ART fillings in primary dentition compared with restoration approaches by drilling and restoration with amalgam, composite resin, and compomer. There is a need for establishing the best scientific evidence about restorative treatment, thus present systematic review was done to assess the survival rate of ART compared with conventional treatment procedures in primary dentition.
| Materials and Methods|| |
This systematic review was done in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analysis statement (CRD42021213729). Randomized controlled trials (RCTs) which compared the survival rate of ART and conventional restorative treatments (CRT) using the same or different restorative materials to treat carious lesions published in the English language were identified through a systematic search of PubMed, DOAJ, Google Scholar, and MEDLINE databases.
Several searches were carried out, each combining the term “ART” with the following keywords: conventional restorations, conventional restorative treatments, composite, amalgam, glass ionomer cement, deciduous teeth, and primary teeth. The population, intervention, comparison, and outcome as a search strategy are presented in [Table 1]. A total of 60,255 articles were found after complete search. Out of these, 3629 studies were retrieved after adjusting for duplicates and on applying the filters, namely free full-text, from 2001 to December 2020, articles only in English language, minimum follow-up of 6 months, etc.
After scrutinizing [Figure 1] the title and abstracts, 3514 studies were discarded. The full text of 20 articles was examined from which 14 studies did not fulfill the inclusion criteria and were excluded from the study. Finally, six studies were obtained for the systematic review which fulfilled the inclusion and exclusion criteria.
|Figure 1: PRISMA 2009 flow diagram. Of these, 3629 studies were retrieved after adjusting for duplicates and on applying the filters Figure 1 shows that the remaining 3514 studies were discarded after reviewing the title and abstracts it appeared that these articles clearly did not meet the criteria|
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Inclusion and exclusion criteria
This systematic review includes randomized control trials published between January 2001 and December 2020. RCTs in which ART was compared with conventional treatment on patients in the age group of 6–10 years with minimum follow-up of 6 months. Studies available as open access and free full-text in PubMed, DOAJ, and Google Scholar databases, published in the English language were included in the study. Two independent reviewers conducted data screening and extraction procedures. This information includes a type of restorative material used, method of caries removal, clinical characteristics of the study populations, length of intervention, and restoration outcomes. The discrepancies between the reviewers were solved by discussion and consensus.
Studies on patients with systemic disorders or physical/mental disabilities that hindered dental treatment in the primary care context, as well as children with acute dental discomfort and/or infections, were excluded from the study. Studies in which children had general or dental developmental problems that necessitated specialized treatment (e.g., amelogenesis imperfect and cleft lip/palate) were also excluded from the study.
Literature search and search strategy
Two reviewers independently examined all retrieved titles and abstracts. Any differences in opinion regarding eligibility were resolved through general agreement.
Data extraction was based on the type of restorative material used, method of caries removal, clinical characteristics of the study populations, length of intervention, and restoration outcomes. Approval from ethical and scientific committee was acquired [Table 2].
Risk of bias
The risk of bias for this systematic review is shown in [Figure 2]. The final six studies were assessed corresponding to the six domains of Cochrane to assess the risk of bias: selection bias, performance bias, detection bias, follow-up bias, bias reporting, and other types of bias. [Figure 3] shows the risk of bias summary.
|Figure 2: Risk of bias graph. Shows the risk of bias for this systematic review|
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|Figure 3: Risk of bias summary. Shows the risk of bias for this systematic review|
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| Results|| |
A preliminary search resulted in 60,255 articles out of which six met the inclusion criteria and were chosen for review. From the selected articles, one study compared CRT utilizing amalgam and ART with high-viscosity GIC carried out by de Amorim et al. The survival rates of amalgam restorations (77.3%) and ART (73.5%) restorations after 2 years, were not statistically significantly different, but an effect of “type of surface” (single/multiple) and “cavity filling time” on the survival rates was observed. Amalgam and ART “single-surface” restorations had better survival rates compared to “multiple-surface” restorations using the same material.
Similarly, Honkala et al. and Hilgert et al., conducted studies to evaluate and compare the feasibility and accumulative survival rate for amalgam and ART restored primary molars over 2-year and 3-year follow-ups, respectively. Both studies stated that there was no significant difference in survival of ART and amalgam restorative techniques.
Mijan et al., assessed survival rates after 3.5 years for three different treatment modalities, i.e., the CRT using amalgam, ART using high-viscosity glass ionomer, and ultraconservative treatment (UCT) protocol in primary molars. Even they favored the hypothesis that there the cumulative survival rates of primary molars treated according to the CRT, ART, and UCT protocols had no difference.
Yu et al., formed nine treatment groups where primary molar cavities in 60 Chinese children were divided into 82 Class I and 53 Class II cavity preparations which were restored using two encapsulated high-strength conventional GICs (Fuji IX GP, Ketac-Molar Aplicap) and in 32 Class I preparations which were restored using one encapsulated nongamma 2 amalgam alloy (GK-amalgam). No significant difference in the survival rate was found among the seven groups out of nine, after 2 years of follow-up (P = 0.99). On the other hand, two groups restored with Fuji IX GP and Ketac-Molar Aplicap in Class II cavities prepared to utilize the ART method showed relatively lower survival rates (P < 0.001). They concluded that both treatment modalities the ART hand instrument and conventional rotary instrument were uniformly suitable for high Class I restoration survival, conversely for Class II restoration survival prepared by the conventional method was preferable.
Contrary to the above studies Taifour et al., concluded that when the combined survival of all single- and multiple-surface restorations between the ART and traditional amalgam approaches was compared a statistically significant difference was seen which favored ART approach (P = 0.04). They concluded that the ART approach using glass-ionomer yielded improved results than did the traditional amalgam restorative technique after 3 years.
Among six studies, five studies showed statistically insignificant difference between ART and conventional treatment option and only one study concluded that the ART approach restored with GIC showed better results in primary teeth than the traditional amalgam restorative technique.
| Discussion|| |
The bulk of cavitated dentine carious lesions in primary teeth remain unrestored in various countries and communities worldwide. For these communities, the traditional restoration technique, which involves expensive dental equipment and restorative materials, as well as significant maintenance expenditures, becomes prohibitive. ART was developed in Tanzania in the mid1980s as part of a community-based primary oral health initiative. The procedure involves removing caries with only hand equipment, then filling the created cavity with an adhesive filling substance such as GIC. Due to its added advantage of reducing dental anxiety and pain, it is considered a good alternative to CRT in children.
The primary goal of the ART technique's development was to give dental care to people in developing countries. However, it may be considered in industrialized countries for the introduction of oral health care to very young children, patients with extreme fear or anxiety about dental treatments, mentally and/or physically handicapped patients, bed/homebound elderly, and patients with high-risk caries who require an intermediate treatment option as a temporary solution.
The purpose of this systematic review was to compare the survival rates of atraumatic and conventional restorations in primary teeth. We only considered the most rigorous RCTs in which the restored survival rate was validated after at least 6 months of follow-up. Many practitioners have had conflicts of interest in using ART in their daily practice due to the perception that it has a high failure rate. Within the scope of this review, it is advised that the ART strategy for occluso-proximal and occlusal restorations in primary teeth has shown a comparable survival rate to the standard treatment approach employing rotary or drilling.
Overall, six published RCTs were included in this review, meeting the eligibility criteria. In all RCTs, two treatment groups were seen CRT as the control group and ART as the test group. In a study done by Mijan et al., a third group was observed, i.e., the UCT group. The CRT group followed the standard protocol. Carious lesions were treated with rotary instruments and restored with amalgam/composite/GIC. ART protocol consists of removing soft, completely demineralized carious tissue with hand instruments only and restoring it with adhesive materials. The UCT group involves small dentine carious lesions treated following the ART protocol.
The restorations were assessed using ART restoration criteria. Restorations coded 0 and 1 were marked as survived, those coded 2–6 were grouped as failures, and codes 7–9 were considered censored observations.,,,, Adverse effects were not reported by any study.
Frencken et al. conducted 6.3-year follow-up research and found statistically insignificant differences between ART and conventional amalgam (TA). The participants in this study were on average 13.8-year-old, therefore it was ruled out. Other authors, such as Yip et al., Kalf-Scholte et al., Molina et al., Mandari et al., Mandari et al., Molina et al., and Barata et al., conducted comparable investigations on adult patients or children over the age of 10 years. The abovementioned articles' overall conclusions favored the notion that ART is equally effective in treating dental caries.
A study by Mhaville et al. indicated that no treatment protocol is superior, however, the preparation methods seemed to be operator sensitive. Cervical gaps were noticed when GIC was hand mixed. However, no follow-up was reported for the treatment methods.
In summary, statistically insignificant results were seen (P > 0.05). When primary molars were treated according to the CRT, ART, and UCT methods, no significant differences were seen on the survival rates of single-surface and multiple-surface restorations. Alternative techniques should be used in deprived areas for treating cavitated dentine carious lesions in primary teeth as the CRT is not appropriate for use in these areas. In a clinic scenario, the conventional cavity preparation method was preferable for Class II restoration survival whereas both the ART hand instrument and conventional rotary instrument methods were equally suitable for high Class I restoration survival. The UCT protocol may arise as a new ray of hope, in addition to the prevailing ART approach, for paving cavitated teeth to trouble-free exfoliation. Further research on the use and technique of UCT is still obligatory.
The access to the articles included in the study was limited to only three databases. Limited studies on ART compared CRT using restorative materials such as GIC, composites which are more commonly used than amalgam in primary dentition. An attempt should be made to make the two ends of past and present methods such as ART and CRT meet to give the best treatment option to patients.
| Conclusion|| |
In conclusion, there was no statistically significant difference in the survival rates of single surface and multiple surface in primary molars treated according to the CRT, ART, and UCT protocols. ART being an aerosol-free procedure is well effective in managing dental caries and thus can be considered the treatment of choice for early caries lesions during the COVID era.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]