Atraumatic restorative treatment had similar survival rates to conventional approaches in primary teeth but evidence limited


Atraumatic restorative treatment (ART) involves the removal of so softened carious enamel and dentine with hand instruments and filling the cavity with a adhesive restorative material. Typically this is a high-viscous glass ionomer cement (GIC).   This approach was about 25 years ago  to provide care in less industrialised areas with high disease levels but is now being used as part of a minimally invasive approach in more developed countries.   The aim of this review was to assess whether occluso- proximal ART restorations are as successful as conventional restorations in primary teeth in terms of longevity, pulp damage, or caries lesion progression.

A detailed search was conducted in only a single database (PubMed) and the reference lists of identified articles.  Only randomised controlled trials in English were included. An assessment of study quality was undertaken.

  • Three trials were included
  • Only restoration longevity of the treatments could be assessed in the studies
  • The pooled estimate for ART success was 1.04 (95% CI  0.65- 1.66)

The authors concluded

Atraumatic restorative treatment restorations performed with high-viscous GIC present similar survival/success rates to conventional approach using composite resin or amalgam for occluso-proximal restorations in primary teeth and can be suggested as a good option for occluso-proximal cavities in primary molars.


As this review does not search two databases it should not really be considered a systematic review.  It could also be considered doubtful that it adds much to an area that already seems to be burdened with a multitude of reviews.  Indeed there are probably now almost as many reviews of this topic as there are trials (see links).  The recent review by Mickenautsch and Yengopal in the online Journal of Minimum Intervention in Dentistry probably has the most extensive search of any of the reviews listed below. This study included 18 trials of which 10 were available for abstraction at the time of publication.  They concluded:-

 The current evidence indicates that the failure rate of high-viscosity GIC/ART restorations is not higher than, but similar to that of conventional amalgam fillings after periods longer than one year.

While much has been written about this topic there is little robust evidence, not helped by differences in the interpretation of what ART entails.  Although as the 2009 Cochrane review by Yengopal et al of  dental fillings for the treatment of caries in the primary dentition notes there is also little robust evidence for traditional fillings either, as they concluded:-

It was disappointing that only three trials that compared three different types of materials were suitable for inclusion into this review. There were no significant differences found in all three trials for all of the outcomes assessed. Well-designed, randomised controlled trials comparing the different types of filling materials for similar outcomes are urgently needed in dentistry. There was insufficient evidence from the three included trials to make any recommendations about which filling material to use.


Raggio DP, Hesse D, Lenzi TL, A B Guglielmi C, Braga MM. Is Atraumatic restorative treatment an option for restoring occlusoproximal caries lesions in primary teeth? A systematic review and meta-analysis. Int J Paediatr Dent. 2012 Nov 28. doi: 10.1111/ipd.12013. [Epub ahead of print] PubMed PMID: 23190278.

Frencken JE, Leal SC, Navarro MF. Twenty-five-year atraumatic restorative treatment (ART) approach: a comprehensive overview. Clin Oral Investig. 2012 Oct;16(5):1337-46. doi: 10.1007/s00784-012-0783-4. Epub 2012 Jul 24. PubMed PMID: 22824915; PubMed Central PMCID: PMC3443346.

de Amorim RG, Leal SC, Frencken JE. Survival of atraumatic restorative treatment (ART) sealants and restorations: a meta-analysis. Clin Oral Investig. 2012 Apr;16(2):429-41. doi: 10.1007/s00784-011-0513-3. Epub 2011 Jan 28. Review.  PubMed PMID: 21274581; PubMed Central PMCID: PMC3308010.

Mickenautsch S, Yengopal V. Re: commentary: poor quality evidence suggests that failure rates for atraumatic restorative treatment and conventional amalgam  are similar. Evid Based Dent. 2012;13(3):93-4. doi: 10.1038/sj.ebd.6400884. PubMed PMID: 23059930

Hurst D. Poor quality evidence suggests that failure rates for atraumatic restorative treatment and conventional amalgam are similar. Evid Based Dent. 2012 Jun;13(2):46-7. doi: 10.1038/sj.ebd.6400858. PubMed PMID: 22722413

Mickenautsch S, Yengopal V. Failure rate of atraumatic restorative treatment using high-viscosity glass-ionomer cement compared to that of conventional amalgam restorative treatment in primary and permanent teeth: a systematic review update. Journal of Minimum Intervention in Dentistry 2012 5: 63–124

Mickenautsch S, Yengopal V, Banerjee A. Atraumatic restorative treatment versus amalgam restoration longevity: a systematic review. Clin Oral Investig. 2010 Jun;14(3):233-40. doi: 10.1007/s00784-009-0335-8. Epub 2009 Aug 18. Review.  PubMed PMID: 19688227.

Yengopal V, Harnekar SY, Patel N, Siegfried N. Dental fillings for the treatment of caries in the primary dentition. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD004483. DOI: 10.1002/14651858.CD004483.pub2.

van ‘t Hof MA, Frencken JE, van Palenstein Helderman WH, Holmgren CJ. The atraumatic restorative treatment (ART) approach for managing dental caries: a meta-analysis. Int Dent J. 2006 Dec;56(6):345-51. PubMed PMID: 17243467.

Frencken JE, Van ‘t Hof MA, Van Amerongen WE, Holmgren CJ. Effectiveness of single-surface ART restorations in the permanent dentition: a meta-analysis. J Dent Res. 2004 Feb;83(2):120-3. PubMed PMID: 14742648.

Mjör IA, Gordan VV. A review of atraumatic restorative treatment (ART). Int Dent J. 1999 Jun;49(3):127-31. PubMed PMID: 10858744




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