DOI: 10.1111/ipd.
12013
Is Atraumatic restorative treatment an option for restoring
occlusoproximal caries lesions in primary teeth? A systematic
review and meta-analysis
DANIELA P. RAGGIO*, DANIELA HESSE, TATHIANE L. LENZI, CAMILA A. B. GUGLIELMI
& MARIANA M. BRAGA
Department of Pediatric Dentistry, School of Dentistry, Universidade de S~
International Journal of Paediatric Dentistry 2012; 00: 00-
00
Background. Atraumatic restorative treatment
(ART) has demonstrated good longevity when
used for single-surface restorations, but lower
success rates are reported for occlusoproximal
surfaces.
Aim. This systematic review and meta-analysis
aimed to verify the pooled success rate of occluso-
proximal ART restorations in primary teeth con-
sidering the outcomes: longevity, pulp damage, or
caries lesion progression.
Design. Literature searching was carried out on
the studies reporting clinical trials indexed in
PubMed and in English language, comprising
the outcomes. A meta-analysis was undertaken
considering the results from reviewed studies.
Introduction
Atraumatic restorative treatment (ART) is
considered as a part of minimal intervention
approach. It involves the removal of softened
carious enamel and dentin using only hand
instruments followed by filling the cavity
with an adhesive restorative material1. The
approach was firstly introduced to provide
dental preventive and restorative care to
needy populations in restricted or less-indus-
trialized areas of the world; however, because
of its benefits, ART has been also spread to
developed countries. The technique simplifies
the restorative process and is well accepted by
young children, special needs patients, and
*Correspondence to
D. P. Raggio, Department of Pediatric Dentistry, School of
Dentistry,University of S~
ao Paulo - Av. Prof. Lineu Prestes,
2227 – Cidade Universit ao Paulo, SP – 05508-000 –
aria -S~
Brazil.
E-mail: danielar@usp.br
© 2012 John Wiley & Sons Ltd, BSPD and IAPD
ao Paulo, S~
ao Paulo, Brazil
Results. An initial search resulted in 126 articles,
and three of them were finally selected. The main
reasons for excluding articles were the absence of
control group, as amalgam, composite resin, or
compomer restorations to be compared with ART
(hand excavation + high-viscous GIC). The pooled
estimate (odds ratio; 95% confidence interval) for
ART approach success was 1.04 (0.65–1.66).
Conclusion. Atraumatic restorative treatment res-
torations performed with high-viscous GIC present
similar survival/success rates to conventional
approach using composite resin or amalgam for
occlusoproximal restorations in primary teeth and
can be suggested as a good option for occlusoprox-
imal cavities in primary molars. In addition, fur-
ther randomized controlled clinical investigations
concerning occlusoproximal restorations in
primary teeth are still necessary.
elderly people2,3. Some reports showed that
ART is less painful than traditional tech-
niques4,5, and local anaesthesia is not
necessary6–9.
Currently, the restorative material of choice
for ART is high-viscous glass ionomer cement
(GIC)10. GICs exhibit excellent properties for
restorative dentistry, including thermal
expansion coefficient similar to tooth struc-
ture, capacity to release fluoride, and chemi-
cal bond to enamel and dentin11. GICs have
also exhibited a reduction in bacteria levels at
restoration sites and have demonstrated an
ability to increase fluoride uptake in adjacent
tooth structure; in this way, this material
might be able to halting or slowing down the
carious lesions progression11,12.
Several materials are commonly used to
restore primary teeth, but uncertainty exists
regarding the optimal restorative material for
primary dentition13. Many factors must be
under consideration regarding this choice,
including handling of dental materials in
1
2 D. P. Raggio et al.
clinical practice, their physical and chemical
qualities with emphasis on restorations longev-
ity, as well as their biological properties. Con-
sidering occlusoproximal surfaces in primary
dentition, the longevity of restorative materials
seems to be reduced when compared to occlu-
sal cavities14. Usually, a high failure rate is
associated with the former type of restora-
tion15,16.
Previous studies have been published com-
paring the success rate of ART versus amalgam
restorations in permanent and primary teeth,
mainly in single-surface cavities11,17. In per-
manent dentition, the longevity of ART occlu-
sal restorations is equal to or greater than for
amalgam restorations11,17. In contrast, no dif-
ference was observed in primary teeth17. A
recent meta-analysis 18 evidenced that the sur-
vival rates of single- and multiple-surfaces ART
restorations in primary teeth over the first
2 years were 93% and 62%, respectively. In
most of the studies selected for this previous
review, however, ART restorations were not
compared with conventional technique (dril-
ling and restoring and/or hand excavation
associated with resin composite, amalgam, or
compomer). They were focused mainly on
ART technique or different GIC brands.
To the best of our knowledge, no systematic
review was conducted to investigate the sur-
vival rate of occlusoproximal ART fillings in
primary dentition compared with restorations
approaches using amalgam, composite resin,
and compomers.
This systematic review intended to verify,
in randomized clinical trials, whether occluso-
proximal ART restorations are as successful as
conventional restorations in primary teeth in
terms of longevity, pulp damage, or caries
lesion progression.
Materials and methods
Search strategy
Literature searching was carried out for arti-
cles reporting on clinical trials indexed in
PubMed up to 1 February 2012. The subject
search used a combination of controlled
vocabulary and text words based on the
following search strategy:
(((((((((((((occlu* AND proximal)) OR class
II cavities) OR approximal lesions) OR proxi-
mal lesions) AND primary dentition) OR pri-
mary dentition[MeSH Terms]) OR deciduous
tooth[MeSH Terms]) OR deciduous tooth)
AND ART) OR atraumatic restorative treat-
ment) OR ART approach) OR ART technique)
AND ((((((((((((((((((((occlu* AND proximal))
OR class II cavities) OR approximal lesions)
OR proximal lesions) AND primary dentition)
OR primary dentition[MeSH Terms]) OR
deciduous tooth[MeSH Terms]) OR deciduous
tooth) AND composite resins) OR composite
resins[MeSH Terms]) OR resins) OR dental
amalgam) OR dental amalgam[MeSH Terms])
OR compomers[MeSH Terms]) OR compo-
mers) OR Polyacid-Modified Composite Res-
ins) OR Composite Resins, polyacid-modified)
OR dental restoration, permanent[MeSH
Terms]) OR dental restoration, permanent)
AND (((clinical[Title/Abstract] AND trial
[Title/Abstract]) OR clinical trials[MeSH
Terms] OR clinical trial[Publication Type] OR
random[Title/Abstract] OR random allocation
[MeSH Terms] OR therapeutic use[MeSH
Subheading]))).
Studies were selected for review from the
search results if they presented compliance
with the inclusion criteria: titles/abstracts
relevant to the purpose and article pub-
lished in English. When only a relevant title
without a listed abstract was available, a full
copy of the article was assessed for inclu-
sion. The references of included articles
were cross-checked for additional studies
suitable for inclusion.
For the purpose of this review, ART was
defined as a procedure including caries
removal by hand instruments, using spoon
excavators, and cavity restoration with high-
viscous GIC1,19. Therefore, articles reporting
on treatment procedures and outcomes that
were different from this definition were
excluded. Other criteria for the exclusion of
studies were as follows: non-random alloca-
tion of subjects or no 2-arm longitudinal clin-
ical trial with 6-month minimum follow-up;
dropout higher than 30%; absence of similar
follow-up for subjects of both groups evalu-
ated in the same way; no computable data for
both groups or studies without at least one of
© 2012 John Wiley & Sons Ltd, BSPD and IAPD

the following outcomes: restoration longevity,
caries lesion progression, or pulp damage.
Three postgraduate students were desig-
nated and trained to evaluate the selected arti-
cles. The training was provided by the lectures
to better understand the features of PubMed
(database) and systematic reviews. They read
a number of studies individually and then
compared the results according to inclusion
and exclusion criteria previously determined.
After one month, the same studies were read
again to calculate the intraexaminer agree-
ment. There was no disagreement observed
among the investigators (j = 1.0) and
between the different moments of evaluation,
considering the same examiner (j = 1.0).
Articles review and data extraction
Only articles that matched the inclusion crite-
ria were reviewed further. Full copies of arti-
cles were reviewed independently by the
three reviewers for compliance with the
exclusion criteria. Data related to the out-
comes and regarding the quality aspects of
the studies were recorded in a specific form.
The quality assessment of the trials retained
for data extraction was also judged indepen-
dently by reviewers regarding the evidence
strength. Criteria proposed by a previous sys-
tematic review with regard to minimum
Table 1. Quality score criteria for therapy articles20.
Quality aspect Criteria
Study setting In situ
In vivo
Articles provide How samples were collected
information on: How examiners/patients were
blinded
How operators were trained or
calibrated
Examiner reliability
Sample drop out rate 30–20%
10–19%
<10%
Follow-up period <1 year
1 year
>1 year
Strong evidence: 10–11.
Good evidence: 6–9.
Reasonable evidence: 0–5.
© 2012 John Wiley & Sons Ltd, BSPD and IAPD
ART in occlusoproximal cavities: systematic review 3
intervention approaches20 were used, as
described in Table 1.
In case of disagreement between the evalu-
ators, they reached a consensus in a joint ses-
sion. In case of doubt, external evaluators
were consulted.
Meta-analysis
A meta-analysis was undertaken considering
the three randomized clinical trials retained
for revision and using specific software (Com-
prehensive Meta Analysis 2.2.064; Biostat,
Englewood, NJ, USA). For calculations, the
success rates and sample size of each studied
group (ART and control groups) were used,
permitting software inference of odds ratio
with 95% of confidence interval (OR; 95%
CI). The fixed- and random-effect models
were performed, but the random effect for
the analysis was chosen, as the intrinsic
heterogeneity among studies was considered.
Results
An initial search resulted in 126 articles of
which 3 complied with the inclusion criteria
and were selected for review21–23. After includ-
ing articles references check-up, another arti-
cle was also included for complete revision24.
From the selected articles, one of the stud-
ies compared high-viscous GIC (Ketac Molar)
with compomer (Dyract) as restorative mate-
rials. It was excluded, however, because the
authors did not use ART technique, as they
Points only reported use of hand excavators. In
addition, there was a dropout higher than
1 30%24.
2
1
Finally, three studies were considered
1 eligible for inclusion in this systematic review
21–23
as shown in Figure 1. Details about
1 these studies are given in Table 2. The pooled
1 estimate (OR; 95% CI) for ART success rate
0 was 1.04 (0.65–1.66) (Fig. 2), showing simi-
2 larity between ART and conventional
3
0
approaches. Only restoration longevity of the
1 treatments could be assessed in the studies.
2 No evaluation of separated outcomes was
found in the studies. All reviewed studies
could be scored as good evidence according to
Mickenautsch et al.20
4 D. P. Raggio et al.
Fig. 1. Flowchart of studies selection, retrieval, and inclusion.
Discussion
There are some different conceptions among
dentists and correct use of the ART
approach13. According to Frencken and van
Amerongen25, however, the correct use of
ART involves the removal of soft, completely
demineralized carious tissue with hand
instruments only and restoration with adhe-
sive materials. In practice, GIC appears as the
most predominantly used material10, reasons
why we considered only ART approach with
high-viscous GIC fillings as the intervention
group.
Many dentists show resistance to use ART
in daily practice due to the idea that the
treatment is not effective, presenting high
failure percentage. Within the limitations of
this review, however, it is suggested that ART
approach performed with high-viscous GIC
restorations have shown similar survival rate
to conventional approach using composite
resin for both occlusoproximal and occlusal
restorations in primary teeth after 24-month
follow-up assessment23.
Composite resins have been used in the
treatment of primary molars, and their accep-
tance by clinicians has increased due to their
better physical and clinical properties com-
pared with conventional GICs16,26,27. Indeed,
some studies have found better survival rates
for composite resin restorations compared
with low-viscous GIC when they were used
for occlusoproximal restoration in primary
molars, both after conventional drilling28,29.
A previous systematic review concerning the
restoration of primary teeth with GIC or
resin-modified GIC used in class II cavities
prepared by drilling showed GIC cannot be
recommended for class II cavities in primary
molars30. The authors, however, did not
include ART approach and did not mention
whether studies included had used low- or
high-viscous GIC; consequently, they did not
present data about both types of GIC sepa-
rately. These aspects may explain why this
study is out of the scope of the current
review, as well as conflicting results regarding
GIC survival rate for occlusoproximal restora-
tions in primary teeth.
Studies that had used amalgam or compom-
er as restorative materials for conventional
technique in primary teeth were also
searched. Amalgam restorations were
included because they have been successfully
used as universal posterior restorative mate-
rial for over the time, being considered a
‘gold standard’31. Two studies comparing the
restoration survival between ART technique
using GIC and conventional approach with
amalgam were retrieved in this review21,22.
Even amalgam fillings have sometimes
© 2012 John Wiley & Sons Ltd, BSPD and IAPD
 ART in occlusoproximal cavities: systematic review 5

Conventional
showed low survival rates for occlusoproxi-

Survival rate (%)

mal restorations in primary teeth21. Based

100.0*
42.9*

82.0*
on the available data, it appears that there is
no difference in survival results between
amalgam restorations and ART with high-

48.7

88.9

76.1
ART viscous GIC in occlusoproximal cavities in
primary teeth up to 3-year follow-up.
Conventional
No. Restorations at
start of the study

Another option considered as conventional

approach was compomers. In an attempt to
overcome problems regarding mechanical
425

93
properties of GICs, they were introduced in
ART

96
610

the early 1990s. The low number of failures

9

in clinical trials 32,33 added to a less sensitive

Follow-

3 years

2 years

2 years
period

and easy handling has made the compomers

widely accepted for restoration in paediatric
up

dentistry33,34. No studies with this material

High-viscous GIC Fuji IX and

were eligible, however. One of the reviewed

High-viscous GICs Fuji IX,

Chem Flex and Megalloy

Ketac Molar and non-

studies used a compomer as restorative

associated to Xeno III
gamma-2-amalgam

resin-based Surefil

material, but it solely compared restorative

materials 24 and did not advocate the ART
technique.
Materials

amalgam

Considering these three comparisons

groups, three studies that pointed to the sim-
ilarity between ART using GIC and conven-
Blind assessment

Blind assessment

tional techniques for occlusoproximal

Three examiners

Two examiners

Two examiners
Table 2. Detailed chart related to the studies included in the current systematic review.

surfaces were found, and the meta-analysis

not possible

not possible
Examiner,

results also suggested equivalence between

Number,
blinded

blinded

both approaches. Although one of the stud-

*n.s. = no statistically significant difference between ART and conventional approaches.

ies had included small number of subjects in

each group, the sample size was weighted in
operator training)
Three dentists (no
Operator, Type,

meta-analysis, and the equivalence between

course on ART)
(3-day training
Eight dentists

tested approaches was maintained likewise,

data about

as the pooled estimate of ART survival rate

Number

Dentist

and this confidence interval was considered

(that includes 1).
With regard to the quality of evidence, all
Evaluation

ART criteria

ART criteria

studies were scored from 7 to 9. Considering

criteria
criteria

USPHS

the maximum for strength of evidence that

could vary from 10 to 11 points because it is
mouth

mouth
Design

difficult to design a perfectly blind study for

Parallel
group

Split-

Split-

investigating different restorative materials, a

good strength for this evidence was stated20.
Location

Additionally, despite a wide variation in suc-

School
Clinic

Clinic

cess rate, the trends observed in all studies

were similar, and the variations are compre-
Country

hensible because minimal internal variations

Kuwait

Turkey
Syria

can occur during study conduction and

sometimes cannot be controlled in system-
Reference

atic reviews. Therefore, the present findings

Honkala
et al.21

et al.22

et al.23
Taifour

corroborate that there is not a best option

Ersin

for restoring occlusoproximal cavities in

© 2012 John Wiley & Sons Ltd, BSPD and IAPD

6 D. P. Raggio et al.
Fig. 2. The pooled estimate (OR; 95%CI) for Atraumatic restorative treatment success rate.
primary molars, and both ART and conven-
tional approaches could be used expecting the
same success rate.
One of the reasons why a small number of
studies that complied with the inclusion crite-
ria were found could be the occurrence of
publication bias. Trials with positive findings
are more likely to be published than those
with negative results35. The trials with nega-
tive findings are not published because fre-
quently the editors can reject those studies36
and also because the authors think that those
works present unimportant results and give
up to publishing35. Therefore, two different
hypotheses can be raised. Firstly, studies have
been carried out, and due to these negative
or equivalent results, they have not been
published. Secondly, a lack of reliable studies
investigating the outcome of interest can also
justify the absence of evidence concerning
this topic. Actually, which hypothesis is more
related to the present findings, neither if a
combination of them occurred, cannot be
assured.
In association with publication bias, a possi-
ble limitation of this study has to be stated,
focusing only in PubMed database and studies
published in English language. Nevertheless,
previous studies have not shown that the
occurrence of bias when articles were written
in languages other than English in conven-
tional medicine reviews, interfering only in
alternative or complementary medicine stud-
ies37–39. Regarding databases choice, in gen-
eral, the EMBASE seems to provide many
citations per searching than PubMed40.
Depending on the topic, however, the Pub-
Med can offer an extensive coverage41.
Indeed, the EMBASE can result in a wider
search, but it also results in higher number
of false positives (unnecessarily identified
studies)42. Therefore, the studies finally
selected to review tend to be similar in many
situations.
Generally, the main reasons for not includ-
ing articles in this review were as follows:
studies not involving a control group repre-
sented by conventional technique using as
restorative materials amalgam, composite
resin, or compomer compared with ART res-
toration with high-viscous GIC filling. Many
studies, which were firstly included, evalu-
ated different methods of moisture control on
the survival of proximal ART restorations in
primary molars43,44, pain experience after
ART or conventional approaches 9,45 and per-
formance of different GIC used for ART46–49.
Moreover, some research compared ART
technique with or without cavity condition-
ing50, cavity disinfection51,52, or chemo-
mechanical caries removal53. Additionally, a
high dropout (>30%) was also reason of
exclusion24.
Clinical success of restorations was evalu-
ated only in terms of longevity outcome
through ART or USPHS criteria, considering
special characteristics related to marginal
integrity. The survival rate ranged between
48.7% and 88.9% to ART restorations and
42.9–100.0% to conventional approaches.
These rates were high probably due to the
variability of operators; sample size or caries
lesions size included in studies and not
related to criteria adopted. Lo et al.54 applied
both the ART and USPHS criteria to the same
ART restorations and reported no significant
differences in survival rate of ART restora-
tions between the two criteria in primary
teeth. Another study that used both criteria
in permanent teeth, however, evidenced
higher survival rates when the USPHS was
used55. Differences between primary and
© 2012 John Wiley & Sons Ltd, BSPD and IAPD

permanent teeth could explain the conflicting
results. In addition, permanent teeth were
followed for longer period compared with pri-
mary teeth. Finally, differences in evaluation
criteria definitely seem not explain the wide
success rate in this review or heterogeneity,
as similar rates were observed in studies in
which different criteria were used.
There was no mention of pulp damage and
caries progression in the included studies.
New investigations should pay attention to
these outcomes, because it may be interesting
to evaluate the ‘tooth longevity’ when using
primary teeth. The longevity could also be
related to the presence of this tooth in the
oral cavity and not uniquely to restoration
failure. If the restoration fails, but the primary
tooth is still there, with no signs of caries pro-
gression or pulp damage, the tooth longevity
may be scored as success56.
Other aspects that could be improved in
further studies testing related outcomes of
ART restorations are blinding and operator’s
training. Examiners’ blinding in some type of
studies could be difficult or even not possi-
ble57. As this review comprised most studies
that compared extremely different dental
materials regarding their appearance, it was
expected a low number of blinded studies.
Operators’ training is an essential data to be
reported in reliable clinical trials. Only one
article, however, mentioned this informa-
tion21, reinforcing the need for including and
reporting this step in future studies, and also
the limitation to evaluate the different
appearance of restorative materials.
It can be evidenced that ART could not be
the ideal approach, but it is not inferior to
other available possibilities for occlusoproxi-
mal cavities, and the type of cavities could
possibly be the actual challenge instead of
technique itself.
Based on these aspects, there is a need for
further randomized controlled clinical investi-
gations comparing occlusoproximal ART res-
torations with conventional techniques, using
standardized methodology for evaluating the
success of the treatments, besides longer fol-
low-up to confirm or reject the trend of simi-
larity between approaches that were observed
in the current review.
© 2012 John Wiley & Sons Ltd, BSPD and IAPD
ART in occlusoproximal cavities: systematic review 7
Bullet points
Why this article is important to paediatric dentists
The paediatric dentists must be aware that
nowadays there is no scientific evidence of
treatment superiority between ART and other
treatments, using different dental materials,
for restoring occlusoproximal cavities in
primary teeth.
Conflict of interest
The authors declare no conflict of interest.
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