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Year : 2015  |  Volume : 13  |  Issue : 4  |  Page : 371-377

Survival rate of atraumatic restorative treatment: A systematic review

Department of Public Health Dentistry, K. V. G. Dental College and Hospital, Sullia, D. K., Karnataka, India

Date of Web Publication7-Dec-2015

Correspondence Address:
Mahammad Shareef Hajisaheb Kotyal
Department of Public Health Dentistry, K. V. G. Dental College and Hospital, Sullia, D. K., Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2319-5932.171206

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Background: Atraumatic restorative treatment (ART) approach was developed in the mid-1980s to provide dental preventive and restorative care to underserved populations in areas that are out of reach. This method consists of the removal of infected (soft demineralized carious) tooth tissue with hand instruments only followed by restoring the cleaned cavity and associated pits and fissures with an adhesive restorative material. However, survival of ART restoration is a matter of intense speculation. Aim: To conduct a systematic review of the literature on the survival rate of ART restorations. Materials and Methods: A systematic search was carried out in MEDLINE, PubMed, and Cochrane databases from 1998 to 2014 using the term survival of ART in permanent teeth, primary teeth, ART restorative material. Results: The analysis of abstracts led to the selection of 36 studies. The research reports a survival rate of ART restoration for <2 years, 2–5 years, and >5 years ranging from 44.8% to 100%, 24.4% to 90%, and 72.6% to 86%. Survival of ART restoration is reported to be marginally higher in permanent molars compared to their primary counterparts. Conclusion: This systematic review revealed high survival rates for single-surface ART restorations in both primary and permanent molars. However, long-term clinical studies are scarce, and a level two and level three evidence was observed.

Keywords: Adhesive restorative material, atraumatic restorative treatment, restorations, survival

How to cite this article:
Kotyal MS, Fareed N, Battur H, Khanagar S, Manohar B, Basapathy R. Survival rate of atraumatic restorative treatment: A systematic review. J Indian Assoc Public Health Dent 2015;13:371-7

How to cite this URL:
Kotyal MS, Fareed N, Battur H, Khanagar S, Manohar B, Basapathy R. Survival rate of atraumatic restorative treatment: A systematic review. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2022 Aug 18];13:371-7. Available from: https://www.jiaphd.org/text.asp?2015/13/4/371/171206

  Introduction Top

Dental caries is the most widely spread oral disease in the world, yet it tends to go untreated in underserved communities in both developing and industrialized countries, as oral health is not a priority relative to the social, economic, political, and other problems facing those countries.[1] According to Blinkhorn and Davies, the main reason for not providing dental care revolves around the need for expensive dental equipment and extensively trained personnel. Even in some developed countries, children are deprived of adequate dental care because of fear and economic reasons.[2]

To overcome these difficulties, atraumatic restorative treatment (ART) technique was introduced by WHO in 1994.[3] This approach is based on the principle of maximum preservation of sound tooth tissue and the concept of minimal intervention cavity design. It includes an innovative, largely pain-free restorative treatment employing a material that does not predispose to bacterial recolonization.[4]

ART was developed at the University of Dar es Salaam, Tanzania, as a pilot project and part of a local oral health program. Glass ionomer cements (GICs) are the material of choice for ART due to their ability to bond to dental structures and capacity of releasing and uptaking fluoride, thus working as a constant source of fluoride in the oral cavity.[3] ART is also an essential component of Basic Package of Oral Care. This is regarded as an essential foundation to any oral health-care provision in a country or community.[5]

Studies on ART have traditionally focused on atraumatic perspective of ART, the cost-effectiveness of ART, selection of restorative materials for the ART, properties of dental cements used for ART, etc. The presence of an intact restoration in the prepared cavity without pain, discomfort, marginal leakage, secondary caries, and marginal fracture is a successful restoration. It should be realized that various rates of survival of ART restoration have been reported in the literature, and various reasons are given thereof. This systematic review is thus undertaken with an aim of critically analyzing published literature on the survival of ART restorations. The objective of this review was to identify various factors associated with survival ART restoration.

  Materials and Methods Top

The literature search of publications indexed in the English language was carried out in PubMed, MEDLINE, and Cochrane Library for over a period of 16 years (1998–2014), with the following keywords: Survival of ART restoration in permanent teeth, survival of ART restoration in primary teeth, and material used for ART restoration. The review was carried out according to the standards of Joanna Briggs Institute (JBI)[6] critical appraisal checklist for systematic review. Selection, screening, and inclusion of the manuscripts were performed by the first three authors; studies published in languages other than English were not included. Gray literature was consulted and their inclusion was through mutual discussion by all the authors.

At the first level of screening, 55 abstracts were excluded as they appeared as duplicates in various databases that were searched. At the second level of screening, 232 abstracts had to be excluded as they were not directly related to survival of ART restoration. A total of 85 full-length articles were retrieved, and further 12 records had to be excluded for the following mentioned reasons: One dissertation which could not be accessed, four systematic reviews, two meta-analyses, four studies on cost-effectiveness of ART, and one study on the influence of local anesthesia on the quality of class II ART restoration. At the final stage, 34 records were excluded because of the following parameters studied in those studies: ART component of minimal intervention dentistry (MID), conjoint analysis, comparison of microleakage of GIC restoration, and  Streptococcus mutans Scientific Name Search prevalence before and after cavity preparation during ART.

The remaining records were critically appraised by the first three authors based on JBI critical appraisal check list for systematic reviews.[6] The authors individually evaluated each study on the provided checklist by JBI reviewers' manual. Those records with unanimous acceptance were included; in the event of a tie breaker situation, mutual discussions enabled inclusion/exclusion. The main outcome of our investigation being the "survival of ART restoration," a total of 39 records from 319 retrieved records were considered potentially eligible and sought for further assessment as shown in [Flow Chart 1 [Additional file 1]].

  Results Top

Analysis of 39 records revealed that research on the survival of ART restorations was reported from 1998 onward. Initially observational studies were published; randomized control trials (RCTs) were published 2002 onward. Further analysis of the literature in relation to duration reveals that a maximum of 17 studies were conducted for a period of 2–5 years reporting the survival rate ranging 24–90%. Primary dentition is studied in most of the studies reporting survival rate from 24% to 96%. Class I restorations are reported to have the maximum survival of 100% as evident from our analysis. Fuji IX is the most commonly used restorative material for ART restorations, as shown in [Table 1].
Table 1: Analysis of literature based on a few parameters involved in this review

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When the studies were further analyzed, it was found that 12 randomized control study designs were conducted upon the primary dentition over an evaluation time of mainly 2 years using GIC among cases and other restorative materials such as amalgam, composite, GIC, and ZOE (Zinc Oxide Eugenol) upon controls. The survival rates reported for ART restoration ranged from 32.1% to 96.5% (cases). Most of the studies had an evidence level of 2 as shown in [Table 2].
Table 2: Analysis of survival of ART restorations (randomized control trials)[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30]

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Observational studies accounted to a total of 24 of which 22 were longitudinal studies and 2 followed a retrospective cohort study designs. These studies were all at evidence level 3 and reported a survival rate ranging from 24.4% to 93% for single-surface restorations as shown in [Table 3]. The majority of the observational studies (14 studies) were conducted upon the permanent dentition.
Table 3: Analysis of survival of ART restorations (observational studies)[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54]

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  Discussion Top

This study is an attempt made to evaluate the survival rate of ART restoration. Although ART may appear to be a simple technique, it embodies a philosophy of treatment based on evidence accumulated over the last 21 years of scientific research on oral health promotion. It involves a role in which dental practice emerges from its repetitive restorative cycle and returns to the prevention of caries. It should be realized that organized oral health care is available to only a relatively small proportion of the world's population. Following the development of ART over the years, a reliable caries management approach has become available for use by a much larger segment of the population.[7]

ART is a conservative caries management approach based on the philosophy of MID for dentine lesions involving hand excavation and a restoration with an adhesive filling material resulting in a sealed restoration. An attempt is made in this study to focus upon survival of single- and multiple-surface ART restorations through an analysis of published literature.

A total of 374 abstracts were retrieved from various search engines, and 338 records were excluded for various reasons mentioned above, after removing duplicates with 39 records were available for qualitative synthesis, yielding a mere 11.28% of published literature focusing on the survival of ART restorations. It is important to realize here that this (11.28%) involves all studies focusing on survival of single-surface restoration, multiple-surface restorations, survival based on various types of materials used, criteria employed for evaluation of the restoration, survival on the types of dentition, and comparisons with various other types of restorations signifying a capacity of research in this topic.

Analysis of records shows the survival rate of ART restorations ranging from 24.4% to 96.5% in primary teeth and 43.4–98.4% in permanent teeth, and as the evaluation time increased, the success rates have decreased, in accordance to the reported findings of Frencken et al.[8] Higher survival rates for permanent teeth compared to primary dentition were observed in our analysis, in accordance to the reported findings of Van't Hof et al., and Mickenautsch and Yengopal,[9],[10] an analysis of 15 RCT studies yielded a survival rate of 32.1–96.5%, and the analysis of observational studies yielded survival rate ranging from 24.4% to 93%, suggesting that the survival rates do not change much with changes in the study design, Such a finding is not reported in the literature, and hence interpretation should be done with caution.

In our analysis, a comparison of survival rates of ART with various high viscous GIC material and other conventional restorative materials (amalgam and composite resin restorations) was performed. Survival rates were similar for both the materials in accordance with the findings of Raggio et al. and de Amorim et al.[11],[12]

Survival rates of ART restorations progressively decreased with an increase in the evaluation time, reporting as much as 100% survival for studies with an evaluation time of <2 years, and 90% for 2–5 years, and 80% for an evaluation time for more than 5 years. This trend has been universally observed in various systematic reviews.[10],[11]

Differences exist among the dentists regarding the applicability of ART as a treatment modality for both primary and permanent dentition. Many dentists are reluctant to use the ART in daily practice due to a conception that it might not be effective or successful. However, within the limitations of our review, it is suggested that ART approach performed with GIC restorations have shown similar survival rates compared to conventional approach using composite resin or amalgam for both single- and multiple-surface restorations at least for a 24-month evaluation time.

Amalgam and composite resins have been used in the treatment of dental caries, and their acceptance by clinicians has increased due to their better physical and clinical properties. Though amalgam is considered to be a universal posterior restorative material and a gold standard even then it has showed similar survival rates as ART especially so in the primary dentition for an evaluation time of 2–3 years. These findings are in accordance to the ones reported by Frencken et al., Mickenautsch and Yengopal, Raggio et al., and Studart et al.[7],[8],[10],[11]

GIC is always the material of choice in the ART technique. This is because of its chemical adherence to dental tissue, coefficient of thermal expansion similar to that of a tooth, biocompatibility properties, and caries protective effect through the release of fluoride, which has antibacterial properties, and potentiates remineralization that may prevent the development of secondary caries. Furthermore, GIC restorations may act as a rechargeable fluoride release system. Various brands of the GIC materials have been studied and reported in the literature; we found a higher variability of survival rates with Fuji IX material, ranging from 30.8% to 92.9%, and the success rate decreased with time irrespective of the material used. These findings are in accordance with the ones reported by Studart et al.[7]

Observational studies have not been included in any of the systematic reviews published in the literature, however in our analysis we have found higher survival rates for single-surface restoration compared to multiple-surface restorations. We analyzed literature with regards to the quality of evidence based on JBI criteria.[6] Most of the literature scored at an evidence level of 2.

The outcome of any restorative procedure should be ultimately demonstrated in terms of survival of restoration. Hence, we have focused on the survival of ART restoration rather than other aspects of ART. Clinical success of restorations was evaluated only in terms of longevity outcome through ART or USPHS criteria. The survival rates that we have reported could be argued on the basis of various other factors involved in the ART approach, viz. variability of operators, sample size, or caries lesions size. Differences related to the adopted criteria, differences between primary and permanent teeth, etc. Based on these aspects, it can be just mentioned that there is a need for further randomized controlled clinical investigations on ART restorations involving the above-mentioned aspects under a more standardized methodology for evaluating the survival of ART, besides longer follow-up to confirm or reject the trend of similarity that are observed in the current review. Finally to summarize our results, we state that it can be evidenced that ART may not be an ideal approach, but certainly it is not inferior to other available possibilities. A possible limitation of this study has to be stated, focusing only on studies published in English language. Nevertheless, previous studies have not shown the occurrence of bias when articles were written in languages other than English in conventional medicine reviews.[13],[14],[15]

  Conclusion Top

This systematic review revealed survival rates for single-surface ART restorations in permanent molars, i.e., 98.4%. Clinical studies conducted with children, adolescents, and young adults demonstrate a reliable clinical performance of single-surface and multi-surface ART restorations for <2-year period (ranging from 44.8% to 100%). However, long-term clinical studies are scarce, and most of them focus on occlusal-surface cavities. The survival rates observed, especially for single-surface restorations, confirm the potential of the ART approach for restoring and saving permanent molars.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.[54]

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  [Table 1], [Table 2], [Table 3]

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