Atraumatic restorative treatment (ART)

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Atraumatic restorative treatment was developed as a means of treating caries in children in underserved areas where clinical facilities, electricity and a trained workforce and other resources are limited. Atraumatic restorative treatment (ART) involves the removal, usually without anaesthetic, of caries with hand instruments alone, using a adhesive restorative material.

The aim of this review was to compare the survival of atraumatic restorative treatment in both permanent and primary teeth, when performed in conventional dental clinics and field settings.


A protocol was registered in the PROSPERO database. Searches were conducted in the Medline/PubMed, Scopus, Web of Science and OpenGrey databases. Randomised controlled trials (RCTs) or non-RCTS prospective studies evaluating the survival of ART restorations with at least 12 months follow up and less than 30% drop out were considered. Two reviewers independently selected studies and extracted data. Risk of bias in the RCTs was assessed using the Cochrane RoB 2 tool  and the ROBINS-I tool for non-randomised studies. Random effect meta-analyses were conducted for survival rate in primary and permanent teeth at 12 and 36 months.


  • 34 studies (28 RCTs, 3 Cohorts, 3 non-randomised studies) were included.
  • 21 studies were conducted in field settings and 10 in the dental clinic.
  • 21 studies involved primary teeth, 10 permanent teeth and 3 both dentitions.
  • 9 studies evaluated occlusal surfaces, 7 studies multi-surfaces and 18 occlusal and multi-surfaces with one non specifying surfaces.
  • 15 of the RCTs were considered to be at high risk of bias 10 at unclear risk and 3 at low risk.
  • 4 of the non-randomised studies were at low risk of bias, one a moderate risk and one a serious risk.
  • Pooled proportion of survival rate for primary teeth at 12 and 36 months and in clinical and field settings are shown in the table below.
Primary teeth Clinic Field
Survival (95%CI) Survival (95%CI)
Occlusal 12 months 0.84 (0.77 to 0.90) 0.79 (0.67 to 0.91)
Multi-surface 12 months 0.58 (0.47 to 0.70) 0.51 (0.36 to 0.66)
Occlusal 36 months 0.66 (0.26 to 1.00) 0.83 (0.75 to 0.92)
Multi-surface 36 months 0.55 (0.43 to 0.67) 0.34 (0.10 to 0.58)
  • All the included studies on permanent teeth with 12 months were conducted in a field setting. Pooled proportion of survival rate = 0.96 (95%CI; 0.94 to 0.98) [5 studies].
  • 4 studies evaluated ART survival in permanent teeth at 36 months providing a pooled proportion of survival rate = 0.73(95%CI; 0.62 to 0.85)


The authors concluded: –

Atraumatic restorative treatment (ART) is a feasible approach for primary and permanent teeth in clinical or field settings. It is essential to highlight that this conclusion is based on a naïve comparison, and the high risk of bias of the primary studies must be considered.


The authors have searched a range of databases to identify studies for inclusion. Given the number of studies identified as RCTs that were included some consideration could have been given to excluding the non-randomised studies. However, 15 of the 28 included RCTs were considered to be at high risk of bias with only 3 being assessed as at low risk. The findings suggest that survival times in the field and clinic are similar at both 12 and 36 months. As might be anticipated survival is better for the single rather than multi-surface restorations.

The authors have focussed on ART restoration survival as an outcome but a 2018 Cochrane review (Dental Elf – 10th Jan 2018) compared ART with conventional restorations including 15 RCTs none of which were included in this new review.  All of the studies included in the Cochrane review were at high risk of bias and the quality of the evidence was of very low certainty.  The Cochrane review suggests that ART had a higher rate of restoration failure than conventional restorations so as this new review shows similar ART restoration survival between clinic and field perhaps ART should be limited to field conditions.


Primary Paper

Garbim JR, Laux CM, Tedesco TK, Braga MM, Raggio DP. Atraumatic restorative treatment restorations performed in different settings: systematic review and meta-analysis. Aust Dent J. 2021 Aug 18. doi: 10.1111/adj.12871. Epub ahead of print. PMID: 34407233.

Review protocol on PROSPERO

Other references

Dental Elf – 10th Jan 2018

Atraumatic Restorative Treatment (ART)

Dental Elf – ART blogs



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