Teeth restored using atraumatic restorative treatment may be more likely to fail, but evidence is low quality

Dental caries (tooth decay) has been considered the most common global disease. Conventional methods (drill and fill) involve the use of electric drills to clear away decayed areas of tooth before filling. Local anaesthetic (painkiller) is normally injected to prevent pain during the procedure. Conventional treatments require highly trained dental health personnel, access to electricity, appropriate tools and are more expensive. These factors may limit access especially in underdeveloped regions of service provision. Atraumatic Restorative Treatment (ART) is an alternative approach for managing dental decay, which involves removal of decayed tissue using hand instruments alone, usually without the use of anaesthesia (injected painkiller) and electrical equipment.

What was the research?

A systematic review to evaluate the effects of a minimally invasive approach, namely Atraumatic Restorative Treatment (ART), for the treatment of tooth decay in children and adults (primary and permanent teeth).

Who conducted the research?

The research was conducted by a team led by Mojtaba Dorri of Bristol Oral and Dental School, UK, on behalf of Cochrane Oral Health. Maria Jose Martinez-Zapata, Tanya Walsh, Valeria C.C. Marinho, Aubrey Sheiham and Carlos Zaror were also on the team.

What evidence was included in the review?

We included 15 randomised controlled trials, including 3,760 participants with an average age of 25 years (range 3 to 101) where 48% were male. The follow-up period in the trials ranged from 6 to 36 months. Two of the 15 studies declared financial support from companies that made tooth-filling material. In addition, we found four ongoing studies.

The evidence was up-to-date as of 22 February 2017.

What did the evidence say?

There is low-quality evidence to suggest that primary teeth treated with the ART approach using high viscosity glass ionomer cement may be more likely than those receiving conventional treatment with the same material to result in restoration failure. In the treatment of primary teeth, ART may reduce pain experience compared with conventional treatment. The evidence available for evaluating the differences between ART and conventional treatments using other restorative materials or in permanent teeth is very low quality so we cannot draw any conclusions. None of the included studies reported on negative side effects or costs.

How good was the evidence?

The available evidence is low- to very low-quality. It is likely that further high-quality research may change our findings. There are four ongoing studies that may provide more information in the future.

What are the implications for dentists and the general public?

The available evidence suggests that atraumatic restorative treatment (ART) using high-viscosity glass ionomer (H-GIC) may have a higher risk of restoration failure than conventional treatment for caries lesions in primary teeth, but the evidence is of low-quality and we cannot rely on the findings. We can draw no conclusions about the effects of ART versus conventional treatment when using resin-modified glass ionomer (RM-GIC) or composite because of the very low quality of the evidence. Practitioners should interpret these results with caution.

What should researchers look at in the future?

Further well-designed, adequately powered randomised controlled trials are needed to determine whether the ART approach confers any benefit in terms of success rate or patient experience during treatment in primary and permanent teeth. Future trials should aim to reduce risk of bias and consider potential confounding factors (e.g. type of restoration material, age) in their study designs. Pragmatic, multi-centre, practice-based trials, with independent non-industrial funding could help provide evidence with high validity.


Dorri M, Martinez-Zapata MJ, Walsh T, Marinho VCC, Sheiham (deceased) A, Zaror C. Atraumatic restorative treatment versus conventional restorative treatment for managing dental caries. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD008072. DOI: 10.1002/14651858.CD008072.pub2.

This post is an extended version of the review’s plain language summary, compiled by Anne Littlewood at the Cochrane Oral Health Editorial Base.