Survival percentages of atraumatic restorative treatment ... · care [1] and turn cavity treatment...

REVIEW

Survival percentages of atraumatic restorative treatment (ART)restorations and sealants in posterior teeth: an updated systematicreview and meta-analysis

R. G. de Amorim1& J. E. Frencken2

& D. P. Raggio3& X. Chen4

& X. Hu4& S. C. Leal5

Received: 5 September 2018 /Accepted: 6 September 2018 /Published online: 19 September 2018# Springer-Verlag GmbH Germany, part of Springer Nature 2018

AbstractObjective The aim of the present study is to update the results of two previous meta-analyses, published in 2006 and 2012, on thesurvival percentages of atraumatic restorative treatment (ART) restorations and ARTsealants. The current meta-analysis includesChinese publications not investigated before.Materials andmethods Until February 2017, six databases were interrogated (two English, one Portuguese, one Spanish and twoChinese). Using six exclusion criteria, a group of six independent reviewers selected 43 publications from a total of 1958potentially relevant studies retrieved. Confidence intervals and/or standard errors were calculated and the heterogeneity varianceof the survival rates was estimated.Results The survival percentages and standard errors of single-surface andmultiple-surface ART restorations in primary posteriorteeth over the first 2 years were 94.3% (± 1.5) and 65.4% (± 3.9), respectively; for single-surface ART restorations in permanentposterior teeth over the first 3 years, they were 87.1% (± 3.2); and for multiple-surface ART restorations in permanent posteriorteeth over the first 5 years, they were 77% (± 9.0). The mean annual dentine-carious-lesion-failure percentages in previouslysealed pits and fissures using ART sealants in permanent posterior teeth over the first 3 and 5 years were 0.9 and 1.9%,respectively.Conclusions ARTsingle-surface restorations presented high survival percentages in both primary and permanent posterior teeth, whilstART multiple-surface restorations presented lower survival percentages. ART sealants presented a high-caries-preventive effect.Clinical relevance ART is an effective evidence-based option for treating and preventing carious lesions in primary and perma-nent posterior teeth.

Keywords Sealant . Restoration . Atraumatic restorative treatment . Survival .Meta-analysis . Systematic review

Introduction

It has been more than 30 years since the atraumatic restorativetreatment (ART) was introduced at the 1986 scientific meetingof the Tanzanian Dental Association [1]. Twenty years later,the results of the first meta-analysis on the survival percent-ages of ART sealants and ART restorations in primary andpermanent teeth were published [2]. One of the conclusionswas that the survival percentage of ART restorations per-formed with high-viscosity glass-ionomer cements (HVGIC)was significantly higher than for those performed with low-and medium-viscosity glass-ionomers. Another conclusionwas that the retention percentage of ART/HVGIC sealantswas significantly higher than that of low- and medium-viscosity glass-ionomer.

Electronic supplementary material The online version of this article(https://doi.org/10.1007/s00784-018-2625-5) contains supplementarymaterial, which is available to authorized users.

* R. G. de Amorim

1 Present address: Brasília, Brazil2 Department of Oral Function and Prosthetic Dentistry, Radboud

University Medical Centre, Nijmegen, The Netherlands3 Orthodontics and Pediatric Dentistry Department, School of

Dentistry, University of São Paulo, São Paulo, Brazil4 State Key Laboratory Breeding Base of Basic Science of

Stomatology (Hubei-MOST) &Key Laboratory of Oral BiomedicineMinistry of Education, School and Hospital of Stomatology, WuhanUniversity, Wuhan, China

5 Department of Dentistry, Faculty of Health Sciences, University ofBrasília, Brasília, Brazil

Clinical Oral Investigations (2018) 22:2703–2725https://doi.org/10.1007/s00784-018-2625-5

http://crossmark.crossref.org/dialog/?doi=10.1007/s00784-018-2625-5&domain=pdf

http://orcid.org/0000-0001-6025-6700

https://doi.org/10.1007/s00784-018-2625-5

The secondmeta-analysis on ARTsealants and restorationscovered the literature up to February 2010 and was publishedin 2012 [3]. The review concluded that ART is a good optionfor treating single-surface cavities in primary and permanentteeth and for sealing caries-prone pits and fissures of perma-nent molars.

More recently, during the International Caries ConsensusCollaboration (ICCC) meeting held in Leuven in 2015, ARTwas recognised by experts in cariology and paediatric dentist-ry as a treatment for managing carious lesions. Its restorativecomponent is based on the selective removal of carious tissuesdown to the soft dentine in deep/very deep lesions and to firmdentine in non-deep lesions [4, 5]. The consensus meetingrecommended that clinicians use ARTas an option for treatingprimary and permanent teeth that presented non-cleansablecavitated dentine-carious lesions.

Originally developed for use in underserved communities,ART exceeded expectations. Its use has now been extended toprivate practice in wealthy developed countries [6]. The rationalefor its widespread use lies in the fact that the principles of ARTare in accordance with the contemporary philosophy of dentalcaries management, which is minimal intervention dentistry(MID) [7]. In addition, ART may increase access to oral healthcare [1] and turn cavity treatment into a non- or less-traumaticexperience at any age in comparison to the traditional rotarytreatment [8–10]. It is also worth noting that ART is being con-sidered as a suitable option for treating root carious lesions in theelderly [11] and in patients with special needs [12].

Because of the continuously extending applications of theuse of ART in oral health care, an update of the meta-analyseson the survival percentages of ART sealants and ART restora-tions is required. The aim of the present article is to report thefindings of a systematic review with meta-analyses on thesurvival of ART restorations in primary and permanent poste-rior teeth and on the retention and dentine-carious-lesion-preventive effect of ARTsealants in permanent posterior teeth.

Materials and methods

This systematic review and meta-analysis was conducted andreported following the Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) statement.

Details of the protocol for this systematic review withmeta-analysis were registered on PROSPERO and can beaccessed at: www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016050096.

Data collection

The literature search comprised publications indexed inEnglish language databases (PubMed and Embase), whichincluded publications written in Dutch, German and French;

Portuguese and Spanish language databases (LILACS andBBO); and Chinese language databases (CNKI and VIP).All publications listed until 1 February 2017 were analysed.For the English language databases, the search strategy inPubMed was (Dental Atraumatic Restorative Treatment[MeSH Terms]) OR (Atraumatic Restorative Treatment) OR(ART AND Dental Restoration, Permanent [MeSH Terms])OR (ARTAND Pit and Fissure Sealants [MeSH Terms]) OR(dental AND survival AND ARTAND approach) OR (dentalAND survival AND ART AND technique) OR (GlassIonomer Cements [MeSH Terms] AND Pit and FissureSealants [MeSH Terms]). In the Embase database, the searchstrategy was to use the following categories: (DentalAtraumatic Restorative Treatment) OR (AtraumaticRestorative Treatment) OR (ART AND Dental Restoration,Permanent) OR (ART AND Pit and Fissure Sealants) OR(dental AND survival AND ARTAND approach) OR (dentalAND survival AND ART AND technique) OR (GlassIonomer Cements AND Pit and Fissure Sealants). For thePortuguese and Spanish language databases, the search strat-egies were, respectively: (Tratamento Dentário Restauradorsem Trauma) OR (Cimentos de Ionômeros de Vidro ANDRestauração Dentária Permanente) OR (Cimentos deIonômeros de Vidro AND Selantes de Fossas e Fissuras);(Tratamiento Restaurativo Atraumático Dental) OR(Cementos de Ionómero Vitreo AND Restauración DentalPermanente) OR (Cementos de Ionómero Vitreo ANDSelladores de Fosas y Fisuras). The search strategy in theChinese databases was (非创伤性充填治疗) OR (非创伤性修

复) OR (ART AND 非创性修复) OR (ART AND 无创伤性)OR (ART AND 微创) OR (ART AND 龋) OR (ART AND充填) OR (ARTAND牙).

From the search results, all publications whose titles orabstracts reported on the survival of ART restorations orART sealants were selected. Those that did not meet thisinclusion criterion were immediately excluded. The listsof references of selected publications were cross-checkedfor additional studies suitable for inclusion. The exclusioncriteria for the purpose of this meta-analysis were (1) sur-vival results < 1 year, (2) incorrect (or missing) statisticalsurvival analysis, (3) ART performed by non-graduateddentist/non-graduated dental therapist, (4) low- ormedium-viscosity glass-ionomer or other material usedwith ART restoration or ART sealant, (5) evaluations per-formed by non-graduated dentists/non-graduated dentaltherapists and (6) use of rotary instruments in restorationstermed ART. If the content of a publication was unclear,the authors were contacted by e-mail and requested toreply within a month in order to allow the publication tobe included. Table 1 shows the reason(s) for excluding103 publications.

The sequence followed from retrieving a publication inany of the six mentioned databases to its inclusion in the

2704 Clin Oral Invest (2018) 22:2703–2725

http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016050096

http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016050096

Table 1 Listing of and reasons for exclusion of publications that reported survival of ART restorations and ART sealants

Publication Language Survival< 1 year

Non-graduateddentist/non-graduateddental therapist

Incorrectstatisticalsurvivalanalysis

Non-HVGIC

ARTwithrotaryinstruments

Followed upby a publicationof longerduration

de Souza et al., 2003 [13] English x

Mallow et al., 1998 [14] English x x

Wang et al., 2004 [15] English x

Van den Dungen et al., 2004 [16] Dutch x

Motsei et al., 2001 [17] English x

Abid et al., 2002 [18] English x

Holmgren et al., 2000 [19] English x

Frencken et al., 1994 [20] English x

Smith et al., 1990 [21] English x

Kalf-Scholte et al., 2003 [22] English x

Phantumvanit et al., 1996 [23] English x

Mandari et al., 2001 [24] English x

Mandari et al., 2003 [25] English x


Ho et al., 1999 [27] English x

Oba et al., 2009 [28] English x

Faccin et al., 2009 [29] English x x

Roeleveld et al., 2006 [30] English x

Kemoli et al., 2009 [31] English x x

Barata et al., 2008 [32] English x

Dülgergil et al., 2005 [33] English x

Lopez et al., 2005 [34] English x

Cefaly et al., 2005 [35] English x

Bresciani et al., 2005 [36] English x

Lo & Holmgren, 2001 [37] English x

Yee, 2001 [38] English x

Zanata et al., 2003 [39] English x

de Amorim et al., 2014 [40] English x

Chen et al., 2012 [41] English x

Chen et al., 2012 [42] English x

Taifour et al., 2003 [43] English x


Hesse et al., 2015 [45] English x

da Mata et al., 2014 [46] English x

Ferreira et al., 2013 [47] English x

Bonifácio et al., 2013 [48] English x

Monse et al., 2012 [49] English x


Phonghanyudh et al., 2012 [51] English x

Roshan et al., 2011 [52] English x

Kemoli et al., 2011 [53] English x

da Franca et al., 2011 [54] English x


Carvalho et al., 2010 [56] English x


da Mata et al., 2015 [11] English x

Clin Oral Invest (2018) 22:2703–2725 2705

Table 1 (continued)




Non-HVGIC



Kemoli & Amerongen, 2011[58]

English x


Gonçalves et al., 2015 [60] English x



Arrow, 2015 [63] English x

Hilgert et al., 2016 [64] English x

Dulgergil et al., 2016 [65] English x

Kemoli, 2014 [66] English x

Jordan et al., 2011 [67] English x

Jordan et al., 2010 [68] English x

Unal & Oztas, 2015 [69] English x

Guler & Yilmaz 2013 [70] English x

Chen & Liu, 2013 [71] English x

Ulusu et al., 2012 [72] English x

Dhar & Chen, 2012 [73] English x

Antonson et al., 2012 [74] English x

Sly et al., 2010 [75] English x

Molina et al., 2014 [76] English x

Falbo et al., 2002 [77] Spanish x

Moraes et al., 2004 [78] Portuguese x

Oliveira et al., 2009 [79] Portuguese x

Silva et al., 2005 [80] Portuguese x

Bresciani et al., 2002 [81] Portuguese x

Peres et al., 2005 [82] Portuguese x

Coelho & Ribeiro, 2002 [83] Portuguese x

Ewoldsen et al., 1999 [84] Spanish x

Oliveira, 2000 [85] Portuguese x

Bustamante et al., 2004 [86] Spanish x

Edelberg & Basso, 2000 [87] Spanish x

Figueiredo et al., 1999 [88] Portuguese x

Carvalho et al., 2011 [89] Portuguese x

Pesaressi-Torres et al., 2013 [90] Spanish x

Raggio, 2012 [91] Portuguese x

Santos, 2010 [92] Portuguese x

Zhang & Jin, 2015 [93] Chinese x

Wan et al., 2007 [94] Chinese x

Cao et al., 2011 [95] Chinese x

Guan & Chen, 2005 [96] Chinese x

Ding et al., 2001 [97] Chinese x

Ling et al., 2006 [98] Chinese x

Feng et al., 2003 [99] Chinese x

Yang, 2011 [100] Chinese x

Miao et al., 2008 [101] Chinese x

Hu & Xiao, 2008 [102] Chinese x

Wang, 2006 [103] Chinese x

2706 Clin Oral Invest (2018) 22:2703–2725

meta-analysis is shown in Figs. 1, 2, and 3. By the timethe literature search was carried out, three English submit-ted manuscripts had become known to the authors (per-sonal communication) and were included. Two of thesemanuscripts [12, 115] presented follow-up results of pre-vious publications ([76, 41], respectively); the other [116]presented results published for the first time.

Main characteristics of the included studies are presented inTable 2.

Investigator agreement

For English publications up to 1 June 2005, two investi-gators (MVH and JF) independently extracted the datarelated to the outcomes, as seen in the first publishedmeta-analysis of the ART approach [2]. For English pub-lications between 1 June 2005 and 1 February 2010, twoinvestigators (RGA and JF) were independently responsi-ble for the data extraction, as seen in the updated meta-analysis published in 2012 [3]. The data extraction for thecurrent meta-analysis was performed by a group of sixinvestigators. RGA and JF independently analysed studiespublished in English between 1 February 2010 and 1February 2017 and extracted the survival percentagesand corresponding standard errors or confidence intervals(CI) of the included studies. SL and DR independentlyanalysed studies published in Portuguese and Spanish be-tween 1 February 2010 and 1 February 2017. XH and XCindependently analysed studies published in Chinese up to1 February 2017. In case of a disagreement about extract-ed data between the investigators, consensus was reachedthrough discussion without the need for external consul-tation. One investigator (JF) took part in all three versionsof the meta-analysis.

Quality of the included publications

The quality assessment of the included publications took intoaccount information related to methodological aspects thatshould be part of any clinical trial that aims to test the efficacyof the ART approach. Nine main quality criteria were exam-ined: (1) generation of randomisation sequence, (2) allocationconcealment, (3) training of operators in the ART technique,(4) independency of evaluators, (5) calibration of evaluators,(6) blinding of evaluators, (7) drop-out rate, (8) implementa-tion of a prevention programme in combination with the per-formance of ART restorations and ARTsealants and (9) reportof the sample baseline caries experience. The quality assess-ment was performed qualitatively by classifying each of thestudy criteria as ‘yes’ (low risk of bias), ‘no’ (high risk of bias)or ‘unclear’ (information not precisely reported or uncertaintyabout the potential of bias). A drop-out rate up to 30% wasconsidered a low risk of bias and a drop-out rate not reportedor more than 30% a high risk of bias. Two investigators (RGAand SL) were responsible for extracting data related to thequality assessment of the English publications.

Statistical analysis

The analyses were carried out by a statistician. If onlysurvival percentages and number of sealants/restorationshad been presented in the included publications, the 95%confidence interval (CI) had to be obtained from the sta-tistical tables. CIs were used to calculate the standarderror (SE) for the survival percentages according to thefollowing equation: SE = (upper − lower CI) / 4. Survivalpercentages per year within selected groups were com-bined by meta-analysis. If survival percentages showedhomogeneity, a fixed-effect model was applied. In case

Table 1 (continued)




Non-HVGIC



Leng et al., 2011 [104] Chinese x

Hu et al., 2015 [105] Chinese x

Yan et al., 2016 [106] Chinese x

Wu & Li, 2012 [107] Chinese x

Wang & Sun, 2007 [108] Chinese x

Gao et al., 2004 [109] Chinese x

Pu, 2014 [110] Chinese x

Han et al., 2008 [111] Chinese x

Ling & Wang, 2003 [112] Chinese x

Li & Dou, 2005 [113] Chinese x

Chen, 2010 [114] Chinese x

Clin Oral Invest (2018) 22:2703–2725 2707

of heterogeneity, a random-effect model was used. Thedecision criterion was the p value for the homogeneitytest. I2 values were used to grade the level of heterogene-ity of the survival percentages per survival year.Categorisation of the level of heterogeneity followed thesuggestion presented by the Cochrane Research Group[155]. The meta-analyses were performed in R version3.3.1 using the survcomp package [156].

Results

The complete database used for the meta-analysis comprised atotal of 43 included publications from 22 countries and re-gions: Argentina, Brazil, China, Ecuador, Egypt, HongKong, India, Iraq, Kuwait, Latvia, Malaysia, Mexico,Nigeria, Panama, Pakistan, South Africa, Suriname, Syria,Tanzania, Turkey, Uruguay and Zimbabwe.

Pubmed Embase

826 366

826 Total number of publica�ons retrieved on search strategy

722 Excluded publica�ons, by reading abstracts, for the following reasons:

- ART publica�ons without survival results

- ART survival results obtained from retrospec�ve studies

- ART men�oned in general den�stry publica�ons

- ART men�oned in non-dental publica�ons

- ART related le�ers

- ART publica�ons in non-traceable journals

- Survival results repeated in other journal/language

- Survival results using resin composite

- Survival results on root surfaces

- Survival results on anterior teeth

- Survival results followed up by a publica�on of longer dura�on

- Survival results the same in two publica�ons

104 Number of eligible publica�ons selected for full reading

Added publica�ons:

- personal communica�on12,13,16 (n=3)

107 Number of publica�ons before applica�on of exclusion criteria

Excluded publica�ons (n=65) (Table 1)

42 Included publica�ons for the meta-analysis

Fig. 1 Flowchart of retrievedEnglish publications to includedpublications reporting survivalresults of ART sealants and ARTrestorations

2708 Clin Oral Invest (2018) 22:2703–2725

Homogeneity of survival results

The level of heterogeneity for ART restorations and ARTsealantsby survival year, using I2 as a guide, is presented in Table 3.Heterogeneity was substantial or higher for most of the weightedmean survival percentages of all types of ART restorations andsealant retention, whereas the level of heterogeneity for theweighted mean survival percentages for the dentine-carious-lesion-preventive effect of ART sealants was much lower, evenshowing full homogeneity (survival years 1 and 3).

ART restorations

The survival percentages and standard errors of single- andmultiple-surface ART restorations in primary posterior teethare presented in Tables 4 and 5, respectively. The weightedmean annual failure rates of single- and multiple-surface ARTrestorations in primary posterior teeth over the first 3 yearswere 5 and 17%, respectively.

The survival percentages and standard errors of single- andmultiple-surface ART restorations in permanent posteriorteeth are presented in Tables 6 and 7, respectively. The weight-ed mean annual failure rate of single-surface ART restorationsin permanent posterior teeth over the first 5 years was 4.1%.

The weighted mean annual failure rate of multiple-surfaceART restorations in permanent posterior teeth was 7.3% overthe first year and 10.9% over the first 2 years.

ART sealants

The survival percentages and standard errors of fully and par-tially retained ART sealants in permanent posterior teeth arepresented in Table 8. The weighted mean annual failure ratesof completely lost ART sealants in permanent posterior teethover the first 3 and 4 years were 10.7 and 9.6%, respectively.

The survival percentages and standard errors of dentine-carious-lesion-free previously sealed pits and fissures usingART sealants in permanent posterior teeth are presented inTable 9. The weighted mean annual dentine-carious-lesion-failure rates of previously sealed pits and fissures using ARTsealants in permanent posterior teeth over the first 3 and5 years were 0.9 and 1.9%, respectively.

Quality assessment

Table 10 shows the quality assessment for the includedstudies. Only one trial, which was published as two studyreports [115, 153], presented a low risk of bias for all

BBO LILACS

245 253




- ART publica�ons in non-traceable journals/theses


- ART publica�ons mee�ng at least one of the exclusion criteria




Fig. 2 Flowchart of retrievedPortuguese/Spanish publicationsto included publications reportingsurvival results of ART sealantsand ART restorations

Clin Oral Invest (2018) 22:2703–2725 2709

assessed criteria. None presented a high risk of bias for allassessed criteria. The criterion that was classified as indi-cating a low risk of bias more often was ‘drop-out rate’.Twenty-three trials reported a loss to follow-up rate ofless than 30%, one trial [140, 141] did not mention theloss to follow-up rate, and 10 presented a rate of higherthan 30%. ‘Training of operators’, ‘independency of eval-uators’ and ‘calibration of evaluators’ (crucial aspects oftrials that report on the longevity of ART restorations andsealants) were classified as having a low risk of bias in24, 22 and 26 trials, respectively.

Discussion

Methodological aspects

Compared to the 2012 ART meta-analysis, the number ofincluded studies on ART restorations in primary teeth, as well

as on ART sealants in permanent teeth, had almost doubled,particularly in the first two evaluation years. This substantialincrease in the number of eligible studies was not observed inART studies for restorations in permanent teeth. It seems thatthe ART approach has found in paediatric dentistry its greateracceptance, which can be easily explained by its potential tocause less pain and anxiety and to be less invasive to dentaltissues [7, 8, 10].

Publications were excluded largely because of ‘incor-rect statistical survival analysis’, followed by ‘non-grad-uated dentist/non-graduated dental therapist’ and ‘theuse of non-HVGIC’ restorative materials.

‘Incorrect statistical survival analysis’ referred mainlyto two situations: (1) the use of simple descriptive analy-sis instead of an appropriate survival analysis to obtainthe studied outcome and (2) the report of a unique surviv-al rate for a combination of different types of restorations(single and multiple surfaces), different types of teeth (an-terior and posterior) and different types of dentition

CNKI VIP

610 318




- ART publica�ons in non-traceable journals/theses


- ART publica�ons mee�ng at least one of the exclusion criteria

- Survival results followed up by a publica�on of longer dura�on

- Survival results using resin composite

- Survival results of wedge-shaped defects ART restora�ons

- Survival results of ART sealants in primary teeth




Fig. 3 Flowchart of retrievedChinese publications to includedpublications reporting survivalresults of ART sealants and ARTrestorations

2710 Clin Oral Invest (2018) 22:2703–2725

Table2

Maincharacteristicsof

theincluded

studies

Publication

Age

(years)

Type

ofdentition

Study

environm

ent

Glass-ionom

ercementu

sed

Evaluationcriteria

Honkalaetal.,2003

[117]

2–9(m

ean5.7)

Prim

ary

Dentalclin

icChemFlex

ARTandUSP

HS

Louwetal.,2002

[118]

6–9(m

ean7.3)

Primary

Field

FujiIX

ART

Luo

etal.,1999

[119]and

Loetal.,2001

[120]

6–14

Prim

aryand

perm

anent

Field

ChemFlex

andFu

jiIX

GP

ARTandUSP

HS

Taifouretal.,2002

[121]

6–7

Primary

Dentalclin

icFujiIXandKetacMolar

ART

Yip

etal.,2002

[122]and

Yuetal.,2004

[123]

7–9

Primary

Dentalclin

icFujiIXGPandKetacMolar

Aplicap

ART

Ersin

etal.,2006

[124]

6–10

(mean8.07)

Prim

ary

Field

FujiIX

GP

USP

HS

Van

Gem

ert-Schriksetal.,2007

[125]

Mean6.09

Prim

aryand

perm

anent

Field

Ketac-M

olar

ART

Menezes

etal.,2006

[126]

4–6

Primary

Dentalclin

icKetac-M

olar

Specificforthestudy—

indirect

assessment(photographs)

Yassen,2009

[127]

6–7(6.7)

Prim

ary

Field

Ionofil

ART

Deepa

&Sh

obha,2010[128]

4–9(m

ean5.3)

Primary

Dentalclin

icFujiIXandAmalgomer

CR

ART

Hilg

ertetal.,

2014

[129]and

Hilg

ertetal.,

2015

[130]

andHilg

ertetal.,

2017

[116]

6–7(m

ean6.8)

Primaryand

perm

anent

Field

Ketac

Molar

Easym

ixART;p

resenceof

caries

(dentin

allesion);sealantretentio

n(partial/full/n

otpresent)

Molinaetal.,2017

[12]

3–39

(mean13.6)/allpatients

with

disability

Primaryand

perm

anent

Dentalclin

icEquiasystem

andChemfilR

ock

ARTwith

theadditio

nof

onecode

forpulpalinvolvem

ent

Cefalyetal.,2007

[131]

9-16

Permanent

Field

Ketac

Molar

andFujiV

III

ART

Ercan

etal.,2009

[132]

7–12

Permanent

Field

Ketac

Molar

ARTandUSPH

S

Faragetal.,2011

[133]

14–15(m

ean14.6)

Perm

anent

Dentalclin

icARTmodifiedandFD

I—indirect

assessment(diestonereplicas

andphotographs)

Frenckenetal.,1998

[134]

Mean14.1

Permanent

Field

FujiIX

ART

Frenckenetal.,2006

[135]

6–9

Permanent

Dentalclin


ART

Hoetal.,1999

[27]

Adults

(mean25.9

yrs.for

FujiIX

groupand

27.4

yrs.forChemFilS

uperior

group)

Perm

anent

Dentalclin

icFujiIXandChemFilS

uperior


indirect

assessment(radiographs,photographs

anddiestonereplicas)anddirect

assessment(lookingforfractures,

caries

andwear)

Kikwilu

etal.,2001

[136]

8–15

(mean10.8)

Perm

anent

Field

FujiIX

ART

Loetal.,2007

[137]

12–13(m

ean12.5)

Perm

anent

Field

Ketac-M

olar

ARTandUSP

HS

Loh,2003[138]

Mean8.2

Perm

anent

Field

FujiIX

ARTmodified

Mickenautschetal.,1999

[139]

6–11

(mean10.5)

Permanent

Dentalclin


ART

PAHO,2006[140]and

Estupiñán-D

ayetal.,2013

[141]

7–9

Permanent

Field

Not

reported

USP

HS

Rahim

toola&

Van

Amerongen,

2002

[142]

6–16

(mean11.4)

Perm

anent

Field

FujiIX

Specificforthestudy

Clin Oral Invest (2018) 22:2703–2725 2711

Tab

le2

(contin

ued)

Publication

Age

(years)

Type

ofdentition

Study

environm

ent

Glass-ionom

ercementu

sed

Evaluationcriteria

Yip

etal.,2002

[143]and

Gao

etal.,2003

[144]

Adults

(mean34.6)

Perm

anent

Dentalclin

icFujiIXGPandKetac-M

olar

Aplicap


indirectassessment

(radiographs,photographs

anddiestone

replicas)anddirectassessment(looking

forfractures,pain

ofpulpalorigin

and

caries)

Ziraps&

Honkala,2002[145]

8–14

(mean11)

Permanent

Dentalclin

icChemFlex

andFu

jiIX

ART

Ibiyem

ietal.,

2011

[146,147]

8–19

(mean13.1)

Perm

anent

Field

FujiIX

GP

ARTmodified

Zanataetal.,2011

[148]

Pregnantw

omen

(mean19)

Permanent

Dentalclin

icFujiIX

ARTandUSPH

S

Vieiraetal.,2006

[149]

6–8

Permanent

Field

ChemFlex

Presenceof

caries

(dentin

allesion);sealant

retention(partial/full/n

otpresent)

Holmgren

etal.,2013

[150]

12–13

Permanent

Field

Ketac-M

olar

Presenceof

caries

(dentin

allesion);sealant

retention(partial/full/n

otpresent)

Luengas-Q

uinteroetal.,2013

[151]

6–13

Perm

anent(only

sealants

wereincluded

inthis

meta-analysis)

Field

Ketac

Molar

Easym

ixART

Liu

etal.,2014

[152]

7–9(m

ean7.8)

Permanent

Field

Ketac-M

olar

Easym

ixPresenceof

caries

(ICDAScodes4–6);

sealantretentio

n(partial/full/n

otpresent)

Zhang

etal.,2014

[153]and

Zhang

etal.,2017

[115]

7–9(m

ean8)

Permanent

Field

Ketac

Molar

Easym

ixSpecificforthestudy(regarding

sealant

retention)

andpresence

ofcaries

(dentin

allesion)

Beirutietal.,2006

[154]

Mean7.8

Permanent

Dentalclin

icFujiIX

Presenceof

caries

(dentin

allesion);sealant

retention(partial/full)

2712 Clin Oral Invest (2018) 22:2703–2725

(primary and permanent). It is important to highlight that,although the unit of the statistical analysis (the tooth) andthe unit of randomisation (usually the patient or theschool) were different in several included publications,the fact was not considered an exclusion criterion. A formof statistical correction was performed only in a few stud-ies but should be regarded as an important aspect forfuture randomised clinical trials (RCTs) that aim to assessthe longevity of dental restorations.

A large number of ART studies had ‘dental students’ asoperators. It should be highlighted that as students theyare in the process of learning skills and, therefore, cannotbe the prime operators in invasive medical treatmentwhose efficacy is under study. Moreover, given the knownfact that the operator, even among dentists [121, 142,

157], is an important variable in the survival percentageof ART restorations, a decision was made to exclude trialsin which ART restorations were performed by dental stu-dents. So far, studies have reported lower survival resultsfor dental students than for dentists [50, 54, 59].

The exclusion of studies that had used ‘non-HVGIC’restorative materials with the ART approach was based onthe outcomes of the 2006 ART meta-analysis, which con-cluded significantly higher weighted mean survival per-centages for ART restorations and sealants that had usedHVGIC than for those that had used low- or medium-viscosity glass-ionomer [2].

The quality assessment of publications was not used as anexclusion criterion nor as an attempt to perform sensitivity orsubgroup analyses. Instead of using a quality score for each

Table 3 Level of heterogeneity(I2 square) of survival results bydentition, type of cavity andsurvival year

Dentition Type of cavity Survivalyear

Heterogeneityp value

I2 Level

Restorations

Primary Single 1 0.0003 66.8 Substantial

2 0.01 60.3 Substantial

3 5.70 93.5 Quite high

Primary Multiple 1 2.52 86.9 Substantial



Permanent Single 1 8.54 83.0 Substantial




5 0.14 49.9 Moderate

6 0.24 28.0 Low/unimportant

10 n/a n/a n/a

Permanent Multiple 1 0.04 60.5 Substantial


3 n/a n/a n/a

5 n/a n/a n/a

10 n/a n/a n/a

Sealants

Permanent Retention 1 1.83 92.2 Quite high




5 n/a n/a n/a

6 n/a n/a n/a

Permanent Cariesprevention

1 0.56 0.0 No


3 0.54 0.0 No

4 0.14 49.1 Moderate


6 n/a n/a n/a

n/a not applicable

Clin Oral Invest (2018) 22:2703–2725 2713

included publication as a weight for cumulative meta-analysisor meta-regression, the quality assessment was incorporatedonly qualitatively in this systematic review.

Many quality scales and checklists have been proposed inthe literature, but it is still difficult to accept that a genericquality assessment tool can be equally successfully applied

Table 5 Overview of survival results (in %) and standard error (SE) of multiple-surface ART restorations using high-viscosity glass-ionomer cementsin primary posterior teeth by year of survival

Study Country Year of survival

1 2 3

Survival SE Survival SE Survival SE

Ersin et al., 2006 [124] Turkey 83 4.3 76 5.3

Van Gemert-Schriks et al., 2007 [125] Suriname 12 3.0

Honkala et al., 2003 [117] Kuwait 100 6.5 83 11.5

Louw et al., 2002 [118] South Africa 73 3.8

Luo et al., 1999 [119] and Lo et al., 2001 [120] China 54 10.0 43 9.8

Menezes et al., 2006 [126] Brazil 31 10.8

Taifour et al., 2002 [121] Syria 72 2.0 60 2.3 49 2.5

Yip et al., 2002 [122]a and Yu et al., 2004 [123]a China 66 12.8 49 13.8

Yip et al., 2002 [122]b and Yu et al., 2004 [123]b China 65 10.5 55 11.0

Deepa & Shobha, 2010 [128]a India 95.1 3.3

Deepa & Shobha, 2010 [128]b India 88.5 4.4

Hilgert et al., 2014 [129] Brazil 80.9 2.8 66.2 3.5 56.4 3.9

Molina et al., 2017 [12] Argentina 81.6 8.2 81.6 8.2 81.6 8.2

Weighted mean score 76.9 3.8 65.4 3.9 49 12.4

a, b Same study but different glass-ionomer cement

Table 4 Overview of survival results (in %) and standard error (SE) of single-surface ART restorations using high-viscosity glass-ionomer cements inprimary posterior teeth by year of survival


1 2 3

Survival SE Survival SE Survival SE

Honkala et al., 2003 [117] Kuwait 99 2.0 91 4.0

Louw et al., 2002 [118] South Africa 96 2.3

Luo et al., 1999 [119] and Lo et al., 2001 [120] China 93 3.8 94 3.8

Taifour et al., 2002 [121] Syria 95 1.0 91 1.3 86 1.8

Yip et al., 2002 [122]a and Yu et al., 2004 [123]a China 95 3.8 89 6.5

Yip et al., 2002 [122]b and Yu et al., 2004 [123]b China 94 4.5 94 4.5

Ersin et al., 2006 [124] Turkey 100 0.8 97 1.9

Van Gemert-Schriks et al., 2007 [125] Suriname 43 10.9

Menezes et al., 2006 [126] Brazil 82 7.3

Yassen, 2009 [127] Iraq 74 7.3

Deepa & Shobha, 2010 [128]a India 97.4 3.4

Deepa & Shobha, 2010 [128]b India 94.9 4.4


Molina et al., 2017 [12] Argentina 100 0.0 100 0.0 100 0.0

Weighted mean score 96.4 1.1 94.3 1.5 85 5.7

a,b Same study but different glass-ionomer cement

2714 Clin Oral Invest (2018) 22:2703–2725

Table6

Overviewof

survivalresults

(in%)andstandard

error(SE)of

single-surface

ARTrestorations

usinghigh-viscosity

glass-ionomer

cementsin

perm

anentp

osterior

teethby

year

ofsurvival

Study

Country

Yearof

survival

12

34

56

10

Survival

SESurvival

SE

Survival

SE

Survival

SE

Survival

SE

Survival

SESurvival

SE

Cefalyetal.,2007

[131]

Brazil

948.0

Ercan

etal.,2009

[132]

Turkey

868.9

819.4

Faragetal.,2011

[133]

Egypt

962.4

855.4

Frenckenetal.,1998

[134]

Zim

babw

e99

0.8

941.8

882.0

Frenckenetal.,2006

[135]

Syria

931.5

881.5

852.0

802.0

762.5

693.0

Van

Gem


[125]

Surinam

e30

8.2

Hoetal.,1999

[27]

HongKong

944.3

Kikwilu

etal.,2001

[136]

Tanzania

961.5

Loetal.,2007

[137]

China

971.0

941.5

902.0

862.0

822.5

743.0

Loh,2003[138]

Malaysia

971.3

961.5

961.5

923.0

Luo

etal.,1999

[119]andLoetal.,2001

[120]

China

962.3

962.3


[139]

South

Africa

942.5

PAHO,2006[140]aandEstupiñán-D

ayetal.,2013

[141]

Ecuador

900.9

831.2

PAHO,2006[140]bandEstupiñán-D

ayetal.,2013

[141]

Uruguay

961.2

941.4

PAHO,2006[140]candEstupiñán-D

ayetal.,2013

[141]

Panam

a98

0.6

970.7

Rahim

toola&

Van

Amerongen,2002

[142]

Pakistan

981.5

942.5

942.3

Yip

etal.,2002

[143]andGao

etal.,2003

[144]

China

100

2.3

947.3

Ziraps&

Honkala,2002[145]

Latvia

934.3

Ibiyem

ietal.,

2011

[146,147]

Nigeria

99.3

0.5

93.5

2.3

Zanataetal.,2011

[148]

Brazil

98.7

1.2

93.6

3.0

86.5

4.9

Molinaetal.,2017

[12]

Argentina

100

0.0

98.8

0.2

98.8

0.2

Weightedmeanscore

96.7

0.8

93.3

1.4

87.1

3.2

85.7

3.2

79.6

1.7

71.5

2.1

86.5

5.7

a,b,cSamestudybutcarried

outindifferentcountries

Clin Oral Invest (2018) 22:2703–2725 2715

to all different types of studies. Since prospective one-armtrials were also included, our decision was to assess singlequality components that were relevant to the longevity ofART restorations and sealants (Table 10) rather than use aformal scale developed only for RCTs. Regarding the compo-nent ‘blinding of evaluators’, it is worth noting that whilst thisis considered extremely important for preventing bias in anydrug medical trial, it seems inappropriate for assessing thequality of dental clinical trials that compare visible differentrestorative materials or deal with one type of restorative ma-terial only. In the present meta-analysis, three of nine studiesin which ‘blinding of evaluators’ would be possible did notperform the blinding properly (Table 10). Despite not beingpossible for all dental clinical trials, blinding should not beneglected in those trials that compare visible similar restor-ative materials in order to reduce the risk of detection bias.

For the 18 included RCTs in which the component‘generation of randomisation sequence’ was consideredto have been undertaken (Table 10), all but four failedto report on adequate allocation concealment, which

shows a high risk of selection bias in these included pub-lications. Taking additionally into account that 19 of 43included publications presented a high risk of bias (or atleast uncertainty about the potential of bias) for more thanhalf of the quality assessment criteria (Table 10), the re-sults of the current meta-analysis should be interpretedwith caution. Even though these results are based on thebest available evidence, their validity is to a certain extentcompromised by the lack of more methodologically re-fined trials.

In order to improve the level of scientific evidence regard-ing the survival of different restorative treatments, two newRCTs comparing ART to conventional treatments have beenconducted using a superior design according to the guidelinesof the Standard Protocol Items: Recommendations forInterventional Trials (SPIRIT) [158, 159]. Although the meth-odological aspects of both trials have been published in detailas study protocols, it should be highlighted that one of thetrials [158] does not make clear if operators in charge of pro-viding restorative treatment are graduated professionals. In

Table 8 Overview of survival results (in %) and standard error (SE) of partially and fully retained ARTsealants in permanent posterior teeth by year ofsurvival


1 2 3 4 5 6

Survival SE Survival SE Survival SE Survival SE Survival SE Survival SE

Frencken et al., 1998 [134] Zimbabwe 90 3.0 86 3.5 71 5.3

Vieira et al., 2006 [149] Brazil 42 6.6

Holmgren et al., 2013 [150]a China 90 2.0 79 3 72 3.5 68 4.2 63 4.7 59 4

Luengas-Quintero et al., 2013 [151] Mexico 72.3 4.3 48.8 5

Liu et al., 2014 [152] China 74.3 3.3 52 3.8

Zhang et al., 2017 [115] China 90.8 1.9 80.7 2.9 66.8 3.5 56 3.9

Hilgert et al., 2017 [116] Brazil 82.2 5.5 67.7 6.5 50.8 8

Weighted mean score 78.7 4.4 69.4 6.1 68 2.0 61.7 6.0 63 4.7 59 4.8

a Additional information extracted from Holmgren et al. [18] and personal communication

Table 7 Overview of survival results (in %) and standard error (SE) of multiple-surface ART restorations using high-viscosity glass-ionomers cementsin permanent posterior teeth by year of survival


1 2 3 5 10

Survival SE Survival SE Survival SE Survival SE Survival SE

Cefaly et al., 2007 [131] Brazil 92 9.1

Ercan et al., 2009 [132] Turkey 59 12.3 41 12.3

Farag et al., 2011 [133] Egypt 97 3.3 77 9.0

Zanata et al., 2011 [148] Brazil 91.2 4.8 94.5 5.8 57.6 10

Molina et al., 2017 [12] Argentina 95.1 1.5 90.3 5.5 90.3 5.5

Weighted mean score 92.7 2.8 78.2 11.7 90.3 5.5 77 9.0 57.6 11.4

2716 Clin Oral Invest (2018) 22:2703–2725

case of them being students, the trial may not give such astrong contribution to the question whether ART restorationssurvive as long as conventional restorative treatments.

The results of the meta-analyses gain in quality even moreif a high level of homogeneity is obtained. Its level is depen-dent on the power of the homogeneity test which is dependenton the number of studies and the respective results and confi-dence intervals. A low p value is usually associated with ahigh I2 percentage. In the present meta-analyses that includeda number of studies from a total of 22 countries and regions,all with different study backgrounds, the level of heterogene-ity of the weighted mean survival percentages for the ARTrestorations was at least substantial. Heterogeneity for theweighted survival percentages of ART sealants was muchlower and even reached the level of homogeneity.

Overall, it is fair to conclude that the required methodolog-ical aspects for performing a meta-analysis have been met tothe highest possible level considering the data available.

Main findings

The weighted mean survival percentages of single-surfaceART/HVGIC restorations in both the 2012 and 2017 meta-analyses were very high. The weighted mean 3-year survivalpercentage of single-surface ART/HVGIC restorations in pri-mary posterior teeth in 2017 (85%) was different from that in2012 (66%), but the difference was not statistically significant.It is fair to conclude that ART can safely be used to restoresingle-surface cavities in primary teeth.

Non-significant differences were found in weighted meansurvival percentage for multiple-surface ART/HVGIC resto-rations in primary posterior teeth over the first 3 years betweenthe 2012 and 2017 ART meta-analyses. The first year weight-ed mean survival percentage of multiple-surface ART

restorations in the 2017 meta-analysis was fairly high, butthe survival percentages at years 2 and 3, although higher thanin 2010, were insufficiently high. Unfortunately, the meta-analyses did not include a category of cavity size, whichwould otherwise have made it possible to recommend theuse of ART/HVGIC restorations in certain sizes of multiple-surface cavities. After all, it is known that large multiple-surface ART/HVGIC restorations fail more frequently thansmaller ones [128, 160]. It is fair to conclude that ART/HVGIC can be used as an alternative method for restoringmultiple-surface cavities in posterior primary teeth, but thatparticularly the larger cavities should not be attempted. Suchcavities can be treated perhaps through an application regimeof silver diamine fluoride [161] or with the ultra-conservativetreatment (UCT) approach, in which large cavities are brushedplaque free with a toothbrush and fluoridated toothpaste [162],or with the Hall technique [163].

The number of included ART studies that investigated thesurvival of restorations in single-surface cavities in permanentposterior teeth at the first 3 years was high to very high. After3 years, however, the number was much lower and the surviv-al outcomes were less reliable, although the standard error wasnot very high. The only long-term (10 years) ART/HVGICsurvival study in single-surface restorations in posterior teethin adults resulted in a survival percentage of 87% [148]. Thisfinding is very high and exceeds the weighted mean annualfailure percentage of 4.1% over the first 5 years found in thepresent meta-analysis. Different from the recommendationthat the ART approach can be safely used to restore single-surface cavities in posterior permanent teeth, insufficient datamake it impossible to give an informed opinion about its usein multiple-surface cavities in posterior permanent teeth.

The weighted mean annual failure rate of fully and partiallyretained ART/HVGIC sealants over the first 3 years was

Table 9 Overview of survival results (in %) and standard error (SE) of caries-free previously sealed pits and fissures using ART sealants in permanentposterior teeth by year of survival


1 2 3 4 5 6

Survival SE Survival SE Survival SE Survival SE Survival SE Survival SE

Frencken et al., 1998 [134] Zimbabwe 98 1.3 98 1.3 96 2.0

Vieira et al., 2006 [149] Brazil 99 1.9

Holmgren et al., 2013 [150]a China 100 0.5 98 0.8 97 1.0 92 2.0 86 3.0 85 3.0

Luengas-Quintero et al., 2013 [151] Mexico 97.5 1.8

Liu et al., 2014 [152] China 99 1.0 93 2.0

Zhang et al., 2014 [153] China 98.9 0.6 98.5 0.6 97.2 0.9 97.3 0.9


Beiruti et al., 2006 [154] Syria 100 0 100 0 98 1.1 95 1.6 94 1.9

Weighted mean score 99.6 0.3 97.8 0.8 97.2 0.6 95.9 0.9 90.5 4.0 85 3.6

a Additional information extracted from Holmgren et al. [18] and personal communication

Clin Oral Invest (2018) 22:2703–2725 2717

Table10

Qualityassessmento

fincluded

studies

Study

Qualityassessmentcriteria

Generationof

random

isation

sequence

Allo

catio

nconcealm

entTrainingof

operators

Independency

ofevaluators

Calibratio

nof

evaluators

Blin

ding

ofevaluators

Com

pleteness

offollo

wup

Implem

entatio

nof

apreventiv

eprogramme

Sam

plebaselin

ecaries

experience

Honkalaetal.,2003

[117]

Yes

No

Yes

No

Unclear

NP/NA

Yes

No

No

Louwetal.,2002

[118]

Yes

No

Yes

Yes

Yes

NP/NA

Yes

Yes

No

Luo

etal.,1999

[119]andLoetal.,2001

[120]

Yes

No

Yes

Yes

Yes

Unclear

Yes

No

No

Taifouretal.,2002

[121]

Yes

No

Yes

Yes

Yes

NP/NA

Yes

Yes

No

Yip

etal.,2002

[122]andYuetal.,2004

[123]

Unclear

No

Yes

Unclear

No

NP/NA

Noa

No

No

Ersin

etal.,2006

[124]

Yes

No

No

Yes

Yes

NP/NA

Yes

No

Unclearb

Van

Gem


[125]

Unclear

No

Yes

No

Yes

NP/NA

Yes

No

Yes

Menezes

etal.,2006

[126]

Yes

Yes

No

Yes

Yes

Yes

Yes

No

No

Yassen,2009

[127]

Yes

No

No

Yes

Yes

Yes

Yes

No

No

Deepa

&Sh

obha,2010[128]

Yes

No

Yes

Yes

Yes

Yes

Yes

No

No

Hilg

ertetal.,

2014

[129]andHilg

ertetal.,

2015

[130]andHilg

ertetal.,

2017

[116]

Yes

No

Yes

Yes

Yes

NP/NA

Yes

Yes

Yes

Molinaetal.,2017

[12]

No

No

No

Yes

Yes

NP/NA

Yes

No

Unclearc

Cefalyetal.,2007

[131]

Unclear

No

Yes

Yes

Yes

Unclear

Yes

Yes

Yes

Ercan

etal.,2009

[132]

Yes

No

Yes

No

Yes

NP/NA

Yes

No

Unclearb

Faragetal.,2011

[133]

No

No

No

Yes

Yes

NP/NA

Noa

Yes

Yes

Frenckenetal.,1998

[134]

No

No

Yes

Yes

No

NP/NA

Noa

Yes

Unclearb

Frenckenetal.,2006

[135]

Yes

No

Yes

Yes

Yes

NP/NA

Noa

Yes

Yes

Hoetal.,1999

[27]

Unclear

Unclear

No

Unclear

Unclear

NP/NA

Yes

No

No

Kikwilu

etal.,2001

[136]

No

No

Unclear

Unclear

Unclear

NP/NA

Yes

No

No

Loetal.,2007

[137]

No

No

Yes

No

Yes

NP/NA

Noa

No

Yes

Loh,2003[138]

No

No

Yes

No

Yes

NP/NA

Noa

No

Unclearb


[139]

Unclear

No

Unclear

Yes

Unclear

Unclear

Noa

No

Unclearb

PAHO,2006[140]andEstupiñán-D

ayetal.,

2013

[141]

Yes

Yes

Yes

Yes

Yes

NP/NA

No

No

No

Rahim

toola&

Van

Amerongen,2002

[142]

Yes

No

Yes

No

Yes

NP/NA

Yes

No

Yes

Yip

etal.,2002

[143]andGao

etal.,2003

[144]

No

No

Unclear

Unclear

Unclear

NP/NA

Yes

No

No

Ziraps&

Honkala,2002[145]

Yes

No

No

Yes

Unclear

Yes

Yes

No

No

Ibiyem

ietal.,

2011

[146,147]

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Zanataetal.,2011

[148]

Unclear

No

Yes

Yes

Yes

NP/NA

Noa

Yes

Yes

Vieiraetal.,2006

[149]

Unclear

Unclear

Yes

Yes

Yes

Yes

Yes

Yes

Yes

2718 Clin Oral Invest (2018) 22:2703–2725

substantial but not significantly different from that reported inthe 2012 meta-analysis: 10.7 versus 9.3%. The difference wasdue to the inclusion of one extra study in 2017 [116] that had alower survival percentage for 3 years of follow-up when com-pared to those from 2012. The 5-year weighted mean survivalpercentage of dentine-carious-lesion-free pits and fissures thathad been sealed was very high and was equal to the compa-rable survival percentage reported in the previous meta-analysis because no additional study with 5 years of follow-up was included in this update. With four more studies in thedatabase, the present meta-analysis ensures that the efficacy ofART/HVGIC sealants in controlling dentine-carious-lesiondevelopment in pits and fissures is well established.

Comparing survival results of ART/HVGICwith traditional restorations and sealants

On the basis of three studies, no significant difference in the 2-year survival percentages between single- and multiple-surface ART/HVGIC and amalgam restorations in primarymolars was reported [164]. For single-surface cavities in pri-mary molars, this finding is supported by a 3-year study thatcompared ART with amalgam restorations [129]. Formultiple-surface cavities in primary molars, a systematic re-view performed with only RCTs concluded that ART/HVGICrestorations have similar survival percentages to conventionaltreatment of amalgam and resin composite restorations [165].The 2017 Cochrane review on ART could not conclude aboutART/HVGIC restorations against amalgam/composite resto-rations in both primary and permanent teeth because of insuf-ficient information. It, however, comparedART/HVGIC treat-ment against a treatment that consists of cleaning the cavitywith rotating instruments and restoring it with the sameHVGIC in multiple surfaces in primary teeth. On the basisof three studies, of which two were carried out with dentalstudents and one with also dental hygienists as operators, thedifference between the two treatments was of borderline sig-nificance, favouring the rotating excavation treatment [166].

Although the weighted mean survival percentages of ART/HVGIC restorations in multiple-surface cavities in posteriorprimary teeth in the present meta-analysis were not high, evi-dence shows that these survival percentages do not differ sig-nificantly from those calculated for conventionally producedrestorations using amalgam or resin composite. It appears thatit is difficult to achieve high restoration survival percentages inmultiple-surface cavities in primary posterior teeth, indepen-dent of the treatment approach and restorative material used.

In comparison with traditional amalgam restorations of thesame size, type of dentition and follow-up period, a systematicreview [164] concluded that ART/HVGIC restorations in per-manent teeth appear to be equally successful and that theirsurvival percentages may even exceed those of amalgam resto-rations. This findingwas corroborated by an updated systematicT

able10

(contin

ued)

Study

Qualityassessmentcriteria

Generationof

random

isation

sequence

Allo

catio

nconcealm

entTrainingof

operators

Independency

ofevaluators

Calibratio

nof

evaluators

Blin

ding

ofevaluators

Com

pleteness

offollo

wup

Implem

entatio

nof

apreventiv

eprogramme

Sam

plebaselin

ecaries

experience

Holmgren

etal.,2013

[150]

No

No

Yes

No

Yes

NP/NA

Noa

Yes

Yes

Luengas-Q

uinteroetal.,2013

[151]

No

No

Yes

Yes

Yes

NP/NA

Yes

Yes

No

Liu

etal.,2014

[152]

Yes

Unclear

Yes

No

Yes

NP/NA

Yes

Yes

No

Zhang

etal.,2014

[153]andZhang

etal.,

2017

[115]

Yes

Yes

Yes

Yes

Yes

NP/NA

Yes

Yes

Yes

Beirutietal.,2006

[154]

Yes

No

Yes

Yes

Yes

NP/NA

Noa

Yes

Yes

NP=notp

ossible(restorativ

ematerialsused

weredifferentinvisualassessment);N

A=notapplicable(1

treatm

entg

roup

only)

aLossto

follo

w-upmorethan

30%

bdfmt/D

MFT

provided

didnotreferto

treatm

entg

roups,buttothewholesampleexam

ined

before

applicationof

inclusioncriteria

cdfmt/D

MFT

provided

didnotrefer

toeach

treatm

entg

roup,but

toalltreated

subjects

Clin Oral Invest (2018) 22:2703–2725 2719

review which concluded that controlled clinical trials withART/HVGIC restorations show that the clinical merits ofHVGIC for direct posterior tooth restorations in permanentteeth are comparable to those of dental amalgam restorations[167]. It appears from these two systematic reviews that thesurvival percentages of ART/HVGIC restorations placed insingle- andmultiple-surface cavities are similar to those of com-parable dental amalgam restorations. It has to be mentioned thatthe level of bias judged to be present in the included trials washigh as is usually the case with trials that have to follow a stricttreatment protocol for ethical and safety reasons.

Compared to the full- and partial-retention survival per-centage of resin-based sealants, the comparable retention sur-vival of ART/HVGIC sealants is lower [168]. But despite thelower full- and partial-retention survival percentage of ART/HVGIC sealants, the dentine-carious-lesion-prevention sur-vival percentage between the two types of sealants is similar[169]. This implies that ART/HVGIC sealants can be appliedwith a high level of success in high-caries-risk pits and fis-sures. In addition, this type of sealant is particularly indicatedfor use in erupting molars where moisture control is compro-mised. The reason is the hydrophilic nature of HVGIC, which,compared to hydrophobic resin-based materials, does not re-quire rubber dam isolation. This isolation is difficult to obtainin erupting molars.

It can be concluded that the dentine-carious-lesion-preventive effect ofART/HVGIC sealants over the first 5 yearsis high; the survival percentage of single-surface ART/HVGIC restorations in posterior primary teeth over the first3 years is high; the survival percentage of multiple-surfaceART/HVGIC restorations in posterior primary teeth over2 years is at a medium level; the survival percentage ofsingle-surface ART/HVGIC restorations in posterior perma-nent teeth over the first 5 years is high; and insufficient data isavailable to draw conclusions about the survival of multiple-surface ART/HVGIC restorations in posterior permanentteeth. Twelve years after the publication of the first meta-anal-ysis, the ART approach has been consistently shown as aneffective evidence-based option for managing carious lesions.The time has come to consider ARTas no longer an alternativeoption, but, for some cases, the treatment of first choice.

Acknowledgements We would like to thank all the authors of the studiesthat made up the database for the current meta-analysis. Special thanks goto Dr. Ewald Bronkhorst for skillful analysis of the data.

Funding The work was partially supported by the National Council forScientific and Technological Development from the BrazilianGovernment, under grants 309521/2015-7 and 306852/2016-0.

Compliance with ethical standards

Conflict of interest RG de Amorim declares that he has no conflictof interest. JE Frencken is the originator of the ART approach and as

such could be considered to have a conflict of interest. DP Raggiohas received research grant from the National Council for Scientificand Technological Development from the Brazilian Government(grant number 309521/2015-7). X Chen declares that she has noconflict of interest. X Hu declares that she has no conflict of inter-est. SC Leal has received research grant from the National Councilfor Scientific and Technological Development from the BrazilianGovernment (grant number 306852/2016-0).

Ethical approval This article does not contain any studies with humanparticipants or animals performed by any of the authors.

Informed consent For this type of study, formal consent is not required.

References

1. Frencken JE, Leal SC, Navarro MF (2012) Twenty-five-yearatraumatic restorative treatment (ART) approach: a comprehen-sive overview. Clin Oral Investig 16:1337–1346

2. van’t Hof MA, Frencken JE, van Palenstein Helderman WV,Holmgren CJ (2006) The atraumatic restorative treatment (ART)approach for managing dental caries: a meta analysis. Int Dent J56:345–351

3. de Amorim RG, Leal SC, Frencken JE (2012) Survival ofatraumatic restorative treatment (ART) sealants and restorations:a meta-analysis. Clin Oral Investig 16:429–441

4. Innes NPT, Frencken JE, Bjorndal L, Maltz M, Manton DJ,Ricketts D et al (2016) Managing carious lesions: consensus rec-ommendations on terminology. Adv Dent Res 28:49–57

5. Schwendicke F, Frencken JE, Bjorndal L, Maltz M, Manton DJ,Ricketts D et al (2016) Managing carious lesions: consensus rec-ommendations on carious tissue removal. Adv Dent Res 28:58–67

6. Holmgren CJ, Roux D, Doméjean S (2013) Minimal interventiondentistry: part 5. Atraumatic restorative treatment (ART)—a min-imum intervention and minimally invasive approach for the man-agement of dental caries. Br Dent J 214:11–18

7. Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, EdenE (2012) Minimal intervention dentistry for managing dental car-ies—a review: report of a FDI task group. Int Dent J 62:223–243

8. Rahimtoola S, van Amerongen E, Maher R, Groen H (2000) Painrelated to different ways of minimal intervention in the treatmentof small caries lesions. ASDC J Dent Child 67:123–127 83

9. Mickenautsch S, Frencken JE, van’t HM (2007) Atraumaticrestorative treatment and dental anxiety in outpatients attend-ing public oral health clinics in South Africa. J Public HealthDent 67:179–184

10. de Menezes Abreu DM, Leal SC, Frencken JE (2009) Self-reportof pain in children treated according to the atraumatic restorativetreatment and the conventional restorative treatment—a pilotstudy. J Clin Pediatr Dent 34:151–155

11. da Mata C, Allen PF, McKenna G, Cronin M, O’Mahony D,Woods N (2015) Two-year survival of ART restorations placedin elderly patients: a randomised controlled clinical trial. J Dent43:405–411

12. Molina GF, Faulks D, Mazzola I, Cabral RJ, Mulder J, FrenckenJE (2018) Three-year survival of ART high-viscosity glass-ionomer and resin composite restorations in people with disability.Clin Oral Investig 22:461–467

13. De Souza EM, Cefaly DF, Terada RS, Rodrigues CC, De LimaNavarro MF (2003) Clinical evaluation of the ART techniqueusing high density and resin-modified glass ionomer cements.Oral Health Prev Dent 1:201–207

2720 Clin Oral Invest (2018) 22:2703–2725

14. Mallow PK, Durward CS, KlaipoM (1998) Restoration of perma-nent teeth in young rural children in Cambodia using theatraumatic restorative treatment (ART) technique and Fuji II glassionomer cement. Int J Paediatr Dent 8:35–40

15. Wang L, Lopes LG, Bresciani E, Lauris JR, Mondelli RF, DeLima Navarro MF (2004) Evaluation of class I ART restora-tions in Brazilian schoolchildren; three-year results. SpecCare Dent 24:28–33

16. Van den Dungen GM, Huddleston Slater AE, Van AmerongenWE (2004) ART of conventioneel? Onderzoeksresultaten vanproximale restauraties in tijdelijke molaren. Ned TijdschrTandheelk 111:345–349

17. Motsei SM, Kroon J, Holtshousen WS (2001) Implementation ofthe ARTapproach in South Africa: an activity report. S Afr Dent J56:327–329

18. Abid A, Chkir F, Ben Salem K, Argoubi K, Sfar-Gandoura M(2002) Atraumatic restorative treatment and glass ionomer seal-ants in Tunisian children: survival after 3 years. East MeditterHealth J 8:315–323

19. Holmgren CJ, Lo ECM, HuDY,WanHC (2000) ART restorationsand sealants placed in Chinese school children—results after threeyears. Community Dent Oral Epidemiol 28:314–320

20. Frencken JE, Songpaisan Y, Phantumvanit P, Pilot T (1994)Atraumatic restorative treatment (ART) technique: evaluation af-ter one year. Int Dent J 44:460–464

21. Smith AJE, Chimimba PD, Kalf-Scholte S, Bouma J (1990)Clinical pilot study on new dental filling materials and preparationprocedures in developing countries. Community Dent OralEpidemiol 18:309–312

22. Kalf-Scholte SM, Van AmerongenWE, Smith AJE, Van HaastrechtHJA (2003) Atraumatic restorative treatment (ART): a three-yearclinical study in Malawi—comparison of conventional amalgamand ART restorations. J Public Health Dent 63:99–103

23. Phantumvanit P, Songpaisan Y, Pilot T, Frencken JE (1996)Atraumatic restorative treatment (ART). Survival of one-surfacerestorations in the permanent dentition. J Public Health Dent 56:141–145

24. Mandari GJ, Truin GJ, Van ‘T Hof MA, Frencken JE (2001)Effectiveness of three minimal intervention approaches for man-aging dental caries: survival of restorations after 2 years. CariesRes 35:90–94

25. Mandari GJ, Frencken JE, Van ‘T Hof MA (2003) Six-year suc-cess rates of occlusal amalgam and glass-ionomer restorationsplaced using three minimal intervention approaches. Caries Res37:246–253

26. Frencken JE, Makoni F, Sithole WD, Hackenitz E (1998) Three-year survival of one-surface ART restorations and glass-ionomersealants in a school oral health programme in Zimbabwe. CariesRes 32:119–126

27. Ho TFT, Smales RJ, Fang DKS (1999) A 2-year clinical study of twoglass ionomer cements used in the atraumatic restorative treatment(ART) technique. Community Dent Oral Epidemiol 27:195–201

28. Oba AA, Dulgergil T, Sonmez IS, Dogan S (2009) Comparison ofcaries prevention with glass ionomer and composite resin fissuresealants. J Formos Med Assoc 108:844–848

29. Faccin ES, Ferreira SH, Kramer PF, Ardenghi TM, Feldens CA(2009) Clinical performance of ART restorations in primary teeth:a survival analysis. J Clin Pediatr Dent 33:295–298

30. RoeleveldAC, vanAmerongenWE,Mandari GJ (2006) Influenceof residual caries and cervical gaps on the survival rate of class IIglass ionomer restorations. Eur Arch Paediatr Dent 7:85–91

31. Kemoli AM, van Amerongen WE, Opinya G (2009) Influence ofthe experience of operator and assistant on the survival rate ofproximal ART restorations: two-year results. Eur Arch PaediatrDent 10:227–232

32. Barata TJE, Bresciani E, Mattos MCR, Lauris JRP, Ericson D,Navarro MFL (2008) Comparison of two minimally invasivemethods on the longevity of glass ionomer cements restorations:short-term results of a pilot study. J Appl Oral Sci 16:155–160

33. Dülgergil CT, Soyman M, Civelek A (2005) Atraumatic restor-ative treatment with resin-modified glass ionomer material: shortterm results of a pilot study. Med Princ Pract 14:277–280

34. Lopez N, Simpser-Rafalin S, Berthold P (2005) Atraumatic restor-ative treatment for prevention and treatment of caries in an under-served community. Am J Public Health 95:1338–1339

35. Cefaly DFG, Barata TJE, Tapety CMC, Bresciani E, NavarroMFL (2005) Clinical evaluation of multisurface ART restorations.J Appl Oral Sci 13:15–19

36. Bresciani E, Carvalho WL, Pereira LCG, Barata TJE, Garcia-Godoy F, Navarro MFL (2005) Six-month evaluation of ARTone-surface restorations in a community with high caries experi-ence in Brazil. J Appl Oral Sci 13:180–186

37. Lo ECM, Holmgren CJ (2001) Provision of atraumatic restorativetreatment (ART) restorations to Chinese pre-school children—a30 month evaluation. Int J Paediatr Dent 11:3–10

38. Yee R (2001) An ART field study in western Nepal. Int Dent J 51:103–108

39. Zanata RL, Navarro MFL, Barbosa SH, Lauris JRP, Franco EB(2003) Clinical evaluation of three restorative materials applied ina minimal intervention caries treatment approach. J Public HealthDent 63:221–226

40. de Amorim RG, Leal SC, Mulder J, Creugers NH, Frencken JE(2014) Amalgam and ART restorations in children: a controlledclinical trial. Clin Oral Investig 18:117–124

41. Chen X, Du M, Fan M, Mulder J, Huysmans MC, Frencken JE(2012) Effectiveness of two new types of sealants: retention after 2years. Clin Oral Investig 16:1443–1450

42. Chen X, DuMQ, Fan MW,Mulder J, Huysmans MC, Frencken JE(2012) Caries-preventive effect of sealants produced with alteredglass-ionomer materials, after 2 years. Dent Mater 28:554–560

43. Taifour D, Frencken JE, Beiruti N, van’t Hof MA, Truin GJ, vanPalenstein Helderman WH (2003) Comparison between restora-tions in the permanent dentition produced by hand and rotaryinstrumentation—survival after 3 years. Community Dent OralEpidemiol 31:122–128

44. Frencken JE, Makoni F, Sithole WD (1996) Atraumatic re-storative treatment and glass-ionomer sealants in a schooloral health programme in Zimbabwe: evaluation after 1 year.Caries Res 30:428–433

45. Hesse D, Bonifácio CC, Guglielmi Cde A, Franca C, MendesFM, Raggio DP (2015) Low-cost glass ionomer cement asART sealant in permanent molars: a randomized clinical trial.Braz Oral Res 29:e63

46. da Mata C, Allen PF, Cronin M, O’Mahony D, McKenna G,Woods N (2014) Cost-effectiveness of ART restorations in elderlyadults: a randomized clinical trial. Community Dent OralEpidemiol 42:79–87

47. Ferreira JM, Pinheiro SL, Sampaio F, Menezes VA (2013) Use ofglass ionomer cement containing antibiotics to seal off infecteddentin: a randomized clinical trial. Braz Dent J 24:68–73

48. Bonifácio CC, Hesse D, Bönecker M, Van Loveren C, VanAmerongen WE, Raggio DP (2013) A preliminary clinicaltrial using flowable glass-ionomer cement as a liner inproximal-ART restorations: the operator effect. Med OralPatol Oral Cir Bucal 18:e529–e532

49. Monse B, Heinrich-Weltzien R, Mulder J, Holmgren C, vanPalenstein Helderman WH (2012) Caries preventive efficacy ofsilver diammine fluoride (SDF) and ART sealants in a school-based daily fluoride toothbrushing program in the Philippines.BMC Oral Health 12:52

Clin Oral Invest (2018) 22:2703–2725 2721

50. Bonifácio CC, Hesse D, Raggio DP, Bönecker M, van Loveren C,van Amerongen WE (2013) The effect of GIC-brand on the sur-vival rate of proximal-ART restorations. Int J Paediatr Dent 23:251–258

51. Phonghanyudh A, Phantumvanit P, Songpaisan Y, Petersen PE(2012) Clinical evaluation of three caries removal approaches inprimary teeth: a randomised controlled trial. Community DentHealth 29:173–178

52. Roshan NM, Sakeenabi B (2011) Survival of occlusal ART resto-rations in primary molars placed in school environment and hos-pital dental setup—one year follow-up study. Med Oral Patol OralCir Bucal 16:e973–e977

53. Kemoli AM, Opinya GN, van Amerongen WE, Mwalili SM(2011) Two-year survival rates of proximal atraumatic restorativetreatment restorations in relation to glass ionomer cements andpost restoration meals consumed. Pediatr Dent 33:246–251

54. da Franca C, Colares V, Van Amerongen E (2011) Two-year eval-uation of the atraumatic restorative treatment approach in primarymolars class I and II restorations. Int J Paediatr Dent 21:249–253

55. Kemoli AM, Opinya GN, van Amerongen WE (2010) Two-yearsurvival of glass ionomer sealants placed as part of proximalatraumatic restorative treatment restorations. East Afr Med J 87:375–381

56. Carvalho TS, Sampaio FC, Diniz A, Bönecker M, VanAmerongen WE (2010) Two years survival rate of class II ARTrestorations in primary molars using two ways to avoid salivacontamination. Int J Paediatr Dent 20:419–425

57. Kemoli AM, van AmerongenWE, Opinya GN (2010) Short com-munication: Influence of different isolation methods on the sur-vival of proximal ART restorations in primary molars after twoyears. Eur Arch Paediatr Dent 11:136–139

58. Kemoli AM, Amerongen WE (2011) Effects of oral hygiene, re-sidual caries and cervical marginal-gaps on the survival of proxi-mal atraumatic restorative treatment approach restorations.Contemp Clin Dent 2:318–323

59. Hesse D, Bonifácio CC, Bönecker M, Guglielmi C de A, daFranca C, van Amerongen WE, Colares V, Raggio DP (2016)Survival rate of atraumatic restorative treatment (ART) resto-rations using a glass ionomer bilayer technique with ananofilled coating: a bi-center randomized clinical trial.Pediatr Dent 38:18–24

60. Gonçalves CF, E Silva MV, Costa LR, de Toledo AO (2015) One-year follow-up of atraumatic restorative treatment (ART) for den-tal caries in children undergoing oncohematological treatment: apragmatic trial. BMC Oral Health 15:127

61. Hesse D, Bonifácio CC, Guglielmi Cde A, Bönecker M, vanAmerongen WE, Raggio DP (2016) Bilayer technique and nano-filled coating increase success of approximal ART restorations: arandomized clinical trial. Int J Paediatr Dent 26:231–239

62. Bonifácio CC, Hesse D, de Oliveira Rocha R, Bönecker M,Raggio DP, van Amerongen WE (2013) Survival rate ofapproximal-ART restorations using a two-layer technique forglass ionomer insertion. Clin Oral Investig 17:1745–1750

63. Arrow P (2016) Restorative outcomes of a minimally invasiverestorative approach based on atraumatic restorative treatment tomanage early childhood caries: a randomised controlled trial.Caries Res 50:1–8

64. Hilgert LA, Frencken JE, de Amorim RG, Mulder J, Leal SC(2016) A study on the survival of primary molars with intact andwith defective restorations. Int J Paediatr Dent 26:383–390

65. Dulgergil CT, Ercan E, Colak H (2016) Evaluation of school-based prevention program in Turkey: results of a 24-month study.Eur J Dent 10:245–249

66. Kemoli AM (2014) The effects of ambient temperature andmixing time of glass ionomer cement material on the survival rate

of proximal ART restorations in primary molars. Contemp ClinDent 5:31–36

67. Jordan RA, Hetzel P, Franke M, Markovic L, Gaengler P, ZimmerS (2011) Class III atraumatic restorative treatment (ART) in adultsliving in West Africa—outcomes after 48 months. CommunityDent Oral Epidemiol 39:164–170

68. Jordan RA, Gaengler P, Markovic L, Zimmer S (2010)Performance of atraumatic restorative treatment (ART) dependingon operator-experience. J Public Health Dent 70:176–180

69. Unal M, Oztas N (2015) Remineralization capacity of three fissuresealants with and without gaseous ozone on non-cavitated incipi-ent pit and fissure caries. J Clin Pediatr Dent 39:364–370

70. Guler C, Yilmaz Y (2013) A two-year clinical evaluation of glassionomer and ormocer based fissure sealants. J Clin Pediatr Dent37:263–267

71. Chen XX, Liu XG (2013) Clinical comparison of Fuji VII and aresin sealant in children at high and low risk of caries. Dent MaterJ 32:512–518

72. Ulusu T, Odabaş ME, Tüzüner T, Baygin O, Sillelioğlu H,Deveci C, Gökdoğan FG, Altuntaş A (2012) The successrates of a glass ionomer cement and a resin-based fissuresealant placed by fifth-year undergraduate dental students.Eur Arch Paediatr Dent 13:94–97

73. Dhar V, Chen H (2012) Evaluation of resin based and glassionomer based sealants placed with or without tooth prepara-tion—a two year clinical trial. Pediatr Dent 34:46–50

74. Antonson SA, Antonson DE, Brener S, Crutchfield J, Larumbe J,Michaud C, Yazici AR, Hardigan PC, Alempour S, Evans D,Ocanto R (2012) Twenty-four month clinical evaluation of fissuresealants on partially erupted permanent first molars: glass ionomerversus resin-based sealant. J Am Dent Assoc 143(2):115–122Erratum in: J Am Dent Assoc 143:336

75. Sly EG, Kaplan AE,Missana L (2010) Clinical evaluation of glassionomer for pit and fissure sealing of fully erupted molars. ActaOdontol Latinoam 23:3–7

76. Molina GF, Faulks D, Mazzola I, Mulder J, Frencken JE (2014)One year survival of ARTand conventional restorations in patientswith disability. BMC Oral Health 14:49

77. Falbo S, Grisoski M, Vivone G, Zac L (2002) Dos años deatención comunitária com técnica atraumática em ninõs escolares.Rev de la Asoc Odontol Argentina 90:171–174

78. Moraes NM, Knupp R, Cabral I (2004) Avaliação de dezoitomeses de um programa de saúde bucal em alunos de uma escolamunicipal do Rio de Janeiro. Rev Bras Odontol 61:227–228

79. OliveiraMT, Bittencourt ST, OliveiraMDS, Roberta H, Pereira JR(2009) Avaliação clínica do desempenho de TRA (tratamentorestaurador atraumático) associado a um agente químico deremoção de cárie. Rev Odonto Ciênc 24:190–193

80. Silva JJS, Carvalho RB, Batittucci MHG, Silva KRS (2005)Tratamento restaurador atraumático (TRA) em escolares doMorro São Benedito, município de Vitória, ES. JBC – J BrasClín OdontolIntegr 9:24–30

81. Bresciani E, Nogueira DA, Henostroza Quintans N, Barata TJE,Lauris JRP, Navarro MFL (2002) Influência do isolamentoabsoluto sobre o sucesso do tratamento restaurador atraumático(ART) em cavidades classe II, em dentes decíduos. Rev FacOdontol Bauru 10:231–237

82. Peres SHCS, Hussne R, Peres AS (2005) Tratamento restauradoratraumático (ART) em crianças de 4 a 7 anos: avaliação clínicaapós 6 meses. Rev Inst Ciênc Saúde 23:275–280

83. Coelho FSM, Ribeiro CCC (2002) Restaurações atraumáticas emodontopediatria (ART). Rev Gaú Odontol 50:105–110

84. Ewoldsen N, Cacho Z, Callahan S, Froeschle ML, GoelBrackettM (1999) Tratamiento restaurador no traumático usando umamezcla de cementos de ionómero de vidrio. Rev Asoc Dent Mex56:8–11

2722 Clin Oral Invest (2018) 22:2703–2725

85. Oliveira LMC (2000) Avaliação de um programa de tratamentorestaurador atraumático em crianças institucionalizadas. Rio deJaneiro; s.n.: 168p, thesis

86. Bustamante C, Edelberg MH (2004) Tratamiento restauradoratraumático (TRA) em dientes permanentes jóvenes. Resultadosde 3 años: un procedimiento válido para la prevención einactivación de caries en el marco de un programa comunitariode atención primaria. Rev Asoc Odontol Argent 92:155–159

87. Edelberg MH, Basso ML (2000) Tratamiento restauradoratraumático. Rev Asoc Odontol Argent 88:43–47

88. Figueiredo MC, Froner AM, Rosito DB, Gallarreta FWM,Sampaio MS (1999) A utilização da técnica de TratamentoRestaurador Atraumático (ART) em bebês: avaliação clínica deum ano. J Bras Odontopediatr Odontol Bebê 2:362–368

89. Carvalho ERT, Filho HRS, Soet H, Gonçalves RM, Knupp R,Groisman S (2011) Avaliação de restaurações realizadas comcimento de ionômero de vidro nacional no tratamento restauradoratraumático. Rev Assoc Paul Cir Dent 65:28–31

90. Pesaressi-Torres E, Garcia-Rupaya C, Villena-Sarmiento R (2013)Evaluacion de sellantes TRA de ionomero de vidrio aplicado enuna comunidad peruana: 12 meses de seguimiento. Kiru 10:3–13

91. Raggio DP (2012) Inspeção do cimento de ionômero de vidroem duas camadas no tratamento restaurador atraumático(Art): estudos in vitro e in vivo. São Paulo; s.n; 2012. 121p. ilus, tab. (BR)

92. Santos CFBF (2010) Aplicabilidade e longevidade do TratamentoRestaurador Atraumático em molars decíduos. Camaragibe; s.n;abr. 2010. 125 p. ilus, tab

93. Zhang W, Jin Y (2015) Clinical effect of glass ionomer preventedpit and fissure sealant of permanent teeth. Journal of DentalPrevention and Treatment 23:163–165

94. Wan H, Hu D, Li X (2007) ARTsealants placed in Chinese schoolchildren—follow up results after 6 years. Journal of PracticalStomatology 23:704–707

95. Cao H, Shu C,Wang S (2011) Cost-effectiveness evaluation of pitand fissure sealant with light-cured flowable resin and ART.Stomatology 31:617–619

96. Guan W, Chen DY (2005) The effect comparison of caries pre-vention by two different pits and fissure sealants. Strait Journal ofPreventive Medicine 11:12–14

97. Ding X, Du An Y, Lu Y et al (2001) Atraumatic restorative treat-ment approach to restore the decayed deciduous teeth: evaluationafter one year. Journal of Modern Stomatology 15:377–379

98. Ling L, Zhang X, Wang X (2006) Clinical research of atraumaticrestorative treatment by using high-strength glass ionomer in pri-mary molars caries and root caries. Stomatology 26:420–421

99. Feng J, Hu D, Wang X et al (2003) ART restoration treatment(ART) restoration root caries in 60-75 year olds study. Journal ofClinical Stomatology 19:28–29

100. Yang Y (2011) Investigation on the effect of atraumatic restorativetreatment restoring primary molar with caries. National MedicalFrontiers of China 6:46–47

101. Miao Y, Jiang Z, Du B (2008) Clinical evaluation of atraumaticrestorative treatment in childhood caries. China Modern Doctor46:18–19

102. Hu ZQ, Xiao R (2008) Study of application on ART tech-nique used to treat root caries. Modern Medicine & Health24:2623–2624

103. Wang YX (2006) Effects of FX glass ionomer sealants on milkteeth molar caries atraumatic restorative treatment. Journal ofMedical Forum 27:11–12

104. Leng C, Ge J, Li B (2011) Comparison of efficacy between twodifferent glass-ionomer cements restoring young permanent teeth.Chinese Community Doctors https://doi.org/10.3969/j.issn.1007-614x.2011.15.127

105. Hu J, Chen Z, Liu J,Wang L, ZhaoW (2015) Analysis of differenttechniques applied in the dental caries treatment of deciduousteeth. Progress in Modern Biomedicine 15:668–671

106. Yan Z, Yan X, Ye M (2016) Evaluation of ART applied to treatdental caries of primary teeth. Medical Frontier 6:182–183

107. Wu H, Li Y (2012) Efficacy comparison of atraumatic restorativetreatment technology and traditional prepared hole repair technol-ogy with glass ionomer cement in the repair of deciduous teethcavity. China Medical Herald 9:30–34

108. Wang XM, Sun LX (2007) Clinical observation of using ARTtechnique on primary molars of 3-5 year olds. Journal ofPractical Stomatology 23:875

109. Gao BX, Li Y, Zhang R, Wang YP (2004) Clinical evaluation ofART technique treating on carious primary teeth. Journal of DentalPrevention and Treatment 12:281

110. PuCM (2014) Observation of 100 cases of ART technique treatingprimary carious teeth. For All Health 8:104

111. Han AJ, Wang XH, Chang ZM (2008) Clinical study of usingART technique treating primary carious teeth. Chinese Journal ofSchool Doctor 24:2623–2624

112. Ling L, Wang XN (2003) Clinical observation of ART techniquetreating on mesio-occlusal cavity of primary teeth. Journal ofDental Prevention and Treatment 11:40–41

113. Li H, Dou ZH (2005) Clinical observation of using different ma-terial in the elderly decayed tooth ART technique. Pract Clin Med6:105–107

114. Chen D (2010) Analysis of applying ART technique to treatingcaries in basic level hospitals. Journal of China TraditionalChinese Medicine Information 2:134–135

115. Zhang WW, Chen X, Fan MW, Mulder J, Frencken JE (2017)Retention rate of four different sealant materials after 4 years.Oral Health Prev Dent 15:307–314

116. Hilgert LA, Leal SC, Freire GML, Mulder J, Frencken JE (2017)3-Year survival rates of retained composite resin and ARTsealantsusing two assessment criteria. Braz Oral Res 31:e35

117. Honkala E, Behbehani J, Ibricevic H, Kerosuo E, Al-Jame G(2003) The atraumatic restorative treatment (ART) approach torestoring primary teeth in a standard dental clinic. Int J PaediatrDent 13:172–179

118. Louw AJ, Sarvan I, Chikte UME, Honkala E (2002) One-yearevaluation of atraumatic restorative treatment and minimal inter-vention techniques on primary teeth. S Afr Dent J 57:366–371

119. Luo Y, Wei SHY, FanMW, Lo ECM (1999) Clinical investigationof a high-strength glass ionomer restorative used with the ARTtechnique in Wuhan, China: one-year results. Chin J Dent Res 2:73–78

120. Lo ECM, Luo Y, FanMW,Wei SHY (2001) Clinical investigationof two glass-ionomer restoratives used with the atraumatic restor-ative treatment approach in China: two-years results. Caries Res35:458–463

121. Taifour D, Frencken JE, Beiruti N, Van’t Hof MA, Truin GJ(2002) Effectiveness of glass-ionomer (ART) and amalgam resto-rations in the deciduous dentition—results after 3 years. CariesRes 36:437–444

122. Yip HK, Smales RJ, Yu C, Deng DM (2002) Comparison ofatraumatic restorative treatment and conventional cavity prepara-tions for glass-ionomer restorations in primary molars: one-yearresults. Quintessence Int 33:17–21

123. Yu C, Gao X-J, Deng D-M, Yip H-K, Smales RJ (2004) Survivalof glass ionomer restorations placed in primary molars usingatraumatic restorative treatment (ART) and conventional cavitypreparations: 2-year results. Int Dent J 54:42–46

124. Ersin NK, Candan U, Aykut A, OnçagO, Eronat C, Kose T (2006)A clinical evaluation of resin-based composite and glass ionomercement restorations placed in primary teeth using the ART ap-proach: results at 24 months. J Am Dent Assoc 137:1529–1536

Clin Oral Invest (2018) 22:2703–2725 2723

http://pesquisa.bvsalud.org/portal/resource/pt/lil-682230



https://doi.org/10.3969/j.issn.1007-614x.2011.15.127

https://doi.org/10.3969/j.issn.1007-614x.2011.15.127

125. Van Gemert-Schriks MC, van Amerongen WE, ten Cate JM,Aartman IH (2007) Three-year survival of single- and two-surface ART restorations in a high-caries child population. ClinOral Invest 11:337–343

126. Menezes JPL, Rosenblatt A, Medeiros E (2006) Clinical evalua-tion of atraumatic restorations in primary molars: a comparisonbetween 2 glass ionomer cements. J Dent Child 73:91–97

127. Yassen G (2009) One-year survival of ART occlusal restorationsin primary molars placed with and without cavity conditioner. JDent Child 76:136–141

128. Deepa G, Shobha T (2010) A clinical evaluation of two glassionomer cements in primary molars using atraumatic restorativetreatment technique in India: 1 year follow up. Int J Paediatr Dent20:410–418

129. Hilgert LA, de Amorim RG, Leal SC, Mulder J, Creugers NH,Frencken JE (2014) Is high-viscosity glass-ionomer-cement a suc-cessor to amalgam for treating primary molars? Dent Mater 30:1172–1178

130. Hilgert LA, Leal SC, Mulder J, Creugers NH, Frencken JE (2015)Caries-preventive effect of supervised toothbrushing and sealants.J Dent Res 94:1218–1224

131. Cefaly DFG, Bresciani E, Lauris JRP, Barata TJE, Fagundes TC,Navarro MFL (2007) Clinical evaluation of multiple-surface ARTrestorations: 12 month follow-up. J Dent Child 74:203–208

132. Ercan E, Dulgergil T, Soyman M, Dalli M, Yildirim I (2009) Afield-trial of two restorative materials used with atraumatic restor-ative treatment in rural Turkey: 24-month results. J Appl Oral Sci17:307–314

133. Farag A, van der Sanden WJM, Abdelwahab H, Frencken JE(2011) Survival of ART restorations, assessed using selectedFDI and the modified ART restoration criteria. Clin Oral Invest15:409–415

134. Frencken JE, Makoni F, Sithole WD (1998) ART restorations andglass ionomer sealants in Zimbabwe: survival after 3 years.Community Dent Oral Epidemiol 26:372–381

135. Frencken JE, Taifour D, Van’t Hof MA (2006) Survival of ARTand amalgam restorations in permanent teeth of children after 6.3years. J Dent Res 85:622–626

136. Kikwilu EN, Mandari GJ, Honkala E (2001) Survival of Fuji IXfillings in permanent teeth of primary school children in Tanzania.East Afr Med J 78:19–21

137. Lo EC, Holmgren CJ, Hu D, van Palenstein HeldermanW (2007)Six-year follow up of atraumatic restorative treatment restorationsplaced in Chinese school children. Community Dent OralEpidemiol 35:387–392

138. Loh KH (2003) An ART technique in the mobile dental squad inMalaysia: a four-year review. Malaysian Dent J 24:95–101

139. Mickenautsch S, Rudolph MJ, Ogunbodede EO, Frencken JE(1999) The impact of the ART approach on the treatment profilein a mobile dental system (MDS) in South Africa. Int Dent J 49:132–138

140. Pan American Health Organization (2006) Oral health of low in-come children. Procedures for atraumatic restorative treatment.Final report. PAHO, Washington

141. Estupiñán-Day S, Tellez M, Kaur S, Milner T, Solari A (2013)Managing dental caries with atraumatic restorative treatment inchildren: successful experience in three Latin American countries.Rev Panam Salud Publica 33:237–243

142. Rahimtoola S, Van Amerongen WE (2002) Comparison of twotooth saving preparation techniques for one surface cavities. JDent Child 69:16–26

143. Yip KH-K, Smales RJ, Gao W, Peng D (2002) The effects of twocavity preparation methods on longevity of glass ionomer cementrestorations. An evaluation after 12 months. J American DentAssoc 133:744–751

144. Gao W, Peng D, Smales R, Yip KHK (2003) Comparison ofatraumatic restorative treatment and conventional restorative pro-cedures in a hospital clinic: evaluation after 30 months.Quintessence Int 34:31–37

145. Ziraps A, Honkala E (2002) Clinical trial of a new glassionomer for an atraumatic restorative treatment technique inclass I restorations placed in Latvian school children. MedPrinc Pract 11:44–47

146. Ibiyemi O, Bankole OO, Oke GA (2011) Assessment ofatraumatic restorative treatment (ART) on the permanent dentitionin a primary care setting in Nigeria. Int Dent J 61:2–6

147. Ibiyemi O, Bankole OO, Oke GA (2011) Survival rates of twoatraumatic restorative treatment (ART) types in occlusal cariouspermanent teeth after two years. Afr J Med Med Sci 40:127–134

148. Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF(2011) Ten-year survival of ART restorations in permanent poste-rior teeth. Clin Oral Investig 15:265–271

149. Vieira ALF, Zanella NLM, Bresciani E, Barata TJE, Silva SMB,Machado MAAM, Navarro MFL (2006) Evaluation of glassionomer sealants placed according to the ART approach in a com-munity with high-caries experience: 1-year follow-up. J Appl OralSci 14:270–275

150. Holmgren CJ, Lo EC, HuD (2013) Glass ionomer ARTsealants inChinese school children—6-year results. J Dent 41:764–770

151. Luengas-Quintero E, Frencken JE, Muñúzuri-Hernández JA,Mulder J (2013) The atraumatic restorative treatment (ART) strat-egy in Mexico: two-years follow up of ART sealants and restora-tions. BMC Oral Health 13:42

152. Liu BY, Xiao Y, Chu CH, Lo EC (2014) Glass ionomer ARTsealant and fluoride-releasing resin sealant in fissure caries pre-vention—results from a randomized clinical trial. BMC OralHealth 14:54

153. Zhang W, Chen X, Fan MW, Mulder J, Huysmans MC, FrenckenJE (2014) Do light cured ART conventional high-viscosity glass-ionomer sealants perform better than resin-composite sealants: a 4-year randomized clinical trial. Dent Mater 30:487–492

154. Beiruti N, Frencken JE, van’t Hof MA, Taifour D, van PalensteinHelderman WH (2006) Caries-preventive effect of a one-time ap-plication of composite resin and glass ionomer sealants after 5years. Caries Res 40:52–59

155. Cumpston M (2013) Exploring heterogeneity—slidecast.Cochrane Training. http://training.cochrane.org/resource/exploring-heterogeneity. Accessed 13 February 2018

156. R Core Team (2017) R: a language and environment for statisticalcomputing. R Foundation for Statistical Computing, Vienna. URLhttps://www.R-project.org/

157. Frencken JE, van’t Hof MA, Taifour D, Al-Zaher I (2007)Effectiveness of ARTand traditional amalgam approach in restor-ing single-surface cavities in posterior teeth of permanent denti-tions in school children after 6.3 years. Community Dent OralEpidemiol 35:207–214

158. Ladewig NM, Sahiara CS, Yoshioka L et al (2017) Efficacy ofconventional treatment with composite resin and atraumatic re-storative treatment in posterior primary teeth: study protocol fora randomised controlled trial. BMJ Open 7:e015542. https://doi.org/10.1136/bmjopen-2016-015542

159. Olegário IC, Hesse D, Bönecker M et al (2016) Effectiveness ofconventional treatment using bulk-fill composite resin versusatraumatic restorative treatments in primary and permanent denti-tion: a pragmatic randomized clinical trial. BMC Oral Health 17:34. https://doi.org/10.1186/s12903-016-0260-6

160. Kemoli AM, van Amerongen WE (2009) Influence of the cavity-size on the survival rate of proximal ART restorations in primarymolars. Int J Paediatr Dent 19:423–430

161. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH (2016) Cariesremineralization and arresting effect in children by professionally

2724 Clin Oral Invest (2018) 22:2703–2725

http://training.cochrane.org/resource/exploring-heterogeneity

http://training.cochrane.org/resource/exploring-heterogeneity

https://www.r-project.org

https://doi.org/10.1136/bmjopen-2016-015542

https://doi.org/10.1136/bmjopen-2016-015542

https://doi.org/10.1186/s12903-016-0260-6

applied fluoride treatment—a systematic review. BMC OralHealth 16:12

162. MijanM, deAmorimRG, Leal SC,Mulder J, Oliveira L, CreugersNH, Frencken JE (2014) The 3.5 year survival rates of primarymolars treated according to three treatment protocols: a controlledclinical trial. Clin Oral Investig 18:1061–1069

163. Innes NP, Evans DJ, Stirrups DR (2011) Sealing caries in primarymolars: randomized control trial, 5-year results. J Dent Res 90:1405–1410

164. Mickenautsch S, Yengopal V, Banerjee A (2010) Atraumatic re-storative treatment versus amalgam restoration longevity: a sys-tematic review. Clin Oral Investig 14:233–240

165. Tedesco TK, Calvo AF, Lenzi TL, Hesse D, Guglielmi CA,Camargo LB, Gimenez T, Braga MM, Raggio DP (2016) ARTis an alternative for restoring occlusoproximal cavities in primary

teeth—evidence from an updated systematic review and meta-analysis. Int J Paediatr Dent 27:201–209

166. Dorri M, Martinez-Zapata MJ, Walsh T, Marinho VCC, SheihamA, Zaror C (2017) Atraumatic restorative treatment versus con-ventional restorative treatment for managing dental caries.Cochrane Database Syst Rev 12:CD008072

167. Mickenautsch S (2016) High-viscosity glass-ionomer cement fordirect posterior tooth restorations in permanent teeth: the evidencein brief. J Dent 55:121–123

168. Frencken JE (2014) The state-of-the-art of ART sealants. DentUpdate 41(119–120):122–124

169. Mickenautsch S, Yengopal V (2016) Caries-preventive effect ofhigh-viscosity glass ionomer and resin-based fissure sealants onpermanent teeth: a systematic review of clinical trials. PLoS One11:e0146512

Clin Oral Invest (2018) 22:2703–2725 2725

Date post:	14-Mar-2019
Category:	Documents
Upload:	nguyenduong
View:	215 times
Download:	0 times

Survival percentages of atraumatic restorative treatment ... · care [1] and turn cavity treatment...

Documents