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Effectiveness of Single-surface ART Restorations in the Permanent Dentition: A Meta-analysis
1 WHO Collaborating Centre for Oral Health Care Planning and Future Scenarios, University of Nijmegen, College of Dental Sciences, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Correspondence: * corresponding author, j.frencken{at}dent.umcn.nl
Over the past few years, there has been an increase in the number of studies reporting on various aspects of the Atraumatic Restorative Treatment (ART) approach. Five randomized clinical trials in which ART restorations with glass ionomers were compared with amalgam restorations in permanent teeth for a maximum period of 3 yrs constituted the database. This meta-analysis divided the publications into ‘early’ (1987–1992) and ‘late’ (1995-) studies on the basis of improvements in the approach. The analysis showed that, in the ‘early’ studies, single-surface amalgam restorations survived statistically significantly longer than comparable ART restorations after 1, 2, and 3 yrs. This trend did not continue into the late group of studies; no statistically significant difference between the 2 types of restorations was found. Based on the available data, it appears that there is no difference in survival results between single-surface ART restorations and amalgam restorations in permanent teeth over the first 3 yrs.
Key Words: dental caries • atraumatic restorative treatment • ART • permanent teeth • meta-analysis
The Atraumatic Restorative Treatment (ART) approach involves the removal of infected tooth tissues with hand instruments, followed by filling the cleaned cavity and associated pits and fissures with an adhesive restorative material (Frencken et al., 1996a). ART is considered one of the minimally invasive operative approaches in the concept of minimal intervention dentistry (Tyas et al., 2000). This relatively new approach requires neither electricity nor plumbed water and, therefore, can be applied in almost any setting. Because a hand-mixed glass ionomer does not require electrically driven equipment, this restorative material was the initial choice of the range of adhesive restorative materials. However, ART does not seem to be confined to places where electricity is absent. Recently, Louw et al.(2002) reported survival of ART restorations produced in dental clinics using a compomer. ART has also been shown to be less painful than conventional approaches (Rahimtoola et al., 2000; Schriks and van Amerongen, 2003), and local anesthesia is rarely required (Phantumvanit et al., 1996; Frencken et al., 1996b; Ho et al., 1999; Mickenautsch et al., 1999; Holmgren et al., 2000; Lo and Holmgren, 2001; Taifour et al., 2003). Since its inception in the mid-1980s, the ART approach has been subjected to research. In the beginning, researchers were interested in the length of survival of ART restorations (Phantumvanit et al., 1996; Frencken et al., 1998a,b). These studies also served to obtain information on technical aspects of the process of removing infected dentin and enamel, and on handling characteristics of the glass ionomer used to provide a sealant restoration. For example, the so-called ‘press-finger’ technique was developed as part of the Thailand study (Phantumvanit et al., 1996). With this technique, the top layer of glass ionomer is pressed into both the cavity and adjoining pits and fissures with the operator’s gloved index finger. Subsequently, this idea was investigated in an in vitro study by Smales et al.(1997). The study showed no statistically significant difference in penetration depth and microleakage in pits and fissures sealed with the glass ionomers used with ART and a resin composite sealant that served as a control. In a review on the ART approach commissioned by the FDI, Mjör and Gordan (1999) recommended that more information was needed on the comparison of restorations produced by ART with those produced with standard conventional approaches. At the time that review was written, only one such study, of only one year’s duration, was available (Smith et al., 1990). Meanwhile, several publications have appeared in the literature recently, reporting comparisons between ART and amalgam approaches. Since the ART approach is being utilized by an ever-increasing number of dental professionals around the world, we considered the need for a first meta-analysis on this topic. The present publication reports the findings of this meta-analysis.
Data Collection The literature search was carried out on publications indexed in PubMed and MEDLINE up to 1 September 2003, with the following Key Words: restorations, survival, permanent (dentition), Atraumatic Restorative Treatment (ART), and amalgam. The search revealed 7 publications (Phantumvanit et al., 1996; Mandari et al., 2001, 2003; Rahimtoola and van Amerongen, 2002; Gao et al., 2003; Kalf-Scholte et al., 2003; Taifour et al., 2003). The inclusion criteria for the meta-analysis consisted of the following: randomized clinical trial, survival results after 1–3 yrs, and sufficient power of the study. One publication had to be excluded because the power of the study was low (Gao et al., 2003), and in one publication, only survival results after 6 yrs were presented (Mandari et al., 2003). These exclusions resulted in 5 studies being eligible for inclusion in the meta-analysis. No additional studies were found in the list of references of the retrieved publications.
The main study characteristics of the 5 studies are described in the Table
Because of the use of different generations of glass ionomers and the accepted learning effect in the first 3 studies, the 5 studies had to be divided into 2 groups: ‘early’ and ‘late’ studies. Thus, homogeneity within the groups was secured.
Investigator Agreement
Statistical Analysis
The differences in survival percentages and the corresponding standard errors between single-surface ART and amalgam restorations per study and for the combined studies after 1, 2, and 3 yrs are presented in Figs. 1  , 2, and 3, respectively. In the early group of studies, single-surface amalgam restorations survived statistically significantly longer than single-surface ART restorations after 1, 2, and 3 yrs. In the late group of studies, there was no statistically significant difference between the 2 types of restorations (large overlap in 95% CI). After 3 yrs, single-surface ART restorations in the late group of studies survived significantly longer than single-surface amalgam restorations in the early group of studies (95% CI are not overlapping).
This is the first meta-analysis in which ART restorations in the permanent dentition have been compared with conventional restorations. The reason we chose amalgam as the comparison restorative material and not resin composite is the fact that amalgam was the material of choice in the countries where the studies had been conducted. Considering the low number of randomized clinical trials constituting this meta-analysis and the necessity to divide the studies into ‘early’ and ‘late’ groups, which reduced the number per unit of analysis even further, one should be careful in drawing conclusions. However, the fact that ART is being researched and being used by many dental health professionals around the world warrants an up-to-date evaluation of how the ART approach compares with conventional restorations. Our decision to divide the 5 studies under analysis into 2 groups is justified by the distinctly different physical characteristics of the restorative materials used and the differences in training received by the operators. The low-viscosity glass ionomers, used in the early studies, were produced for use in low-stress-bearing areas such as cervical cavities. In the absence of an alternative material at that time, they were placed in high-stress-bearing areas such as occlusal cavities as part of the ART approach. After the initial results of some early ART studies, manufacturers produced glass ionomers that were designed to better withstand these high stresses. The commonly held belief that the ART approach is easy for an experienced dental professional to perform has been questioned by some authors (Frencken et al., 1998a,b). The operators in the early studies had not been specifically trained in ART, while those of the later studies had attended a structured ART training course. The meta-analysis showed that single-surface amalgam restorations in the early group of studies survived longer than comparable ART restorations within the first 3 years. This finding is not surprising when one considers the types of glass ionomers used, the absence of cavity conditioning in ART restorations in 2 of the 3 studies, and the operators’ lack of previous experience in performing ART. The finding that the survival percentages of single-surface ART restorations in the late group of studies were significantly higher than those for comparable amalgam restorations for all 3 yrs is of more interest. Unfortunately, the late group of studies constituted of only 1 three-year study, and that calls for caution in the drawing of conclusions with respect to survival of restorations in this group. In conclusion, it appears that single-surface amalgam restorations in permanent teeth in the early studies survived longer than comparable ART restorations over a period of 3 yrs, but there is no evidence that this trend continued into the late group of studies. In the more recently conducted studies, there appears to be no difference between the 2 types of restorations.
This work was supported by institutional funds. Received for publication March 10, 2003. Revision received October 14, 2003. Accepted for publication November 4, 2003.
Journal of Dental Research, Vol. 83, No. 2,
120-123 (2004) This article has been cited by other articles:
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