The effectiveness of Atraumatic Restorative Treatment versus conventional restorative treatment for permanent molars and premolars A critical assessment of existing systematic reviews and report of a new systematic review

Abstract

Background: Atraumatic Restorative Treatment (ART) is the removal of caries using hand instruments and restoration of the resulting cavity using an adhesive restorative material. It was designed to restore teeth in communities without access to conventional dental clinics in poorer countries but has come to be used by dentists in the developed world too, as an alternative to conventional restorative treatment. Objectives: 1) to assess the scope and the methodological and reporting quality of existing systematic reviews of the effectiveness of ART compared to conventional restorative treatment; 2) to evaluate the effectiveness of ART compared to conventional treatment in permanent teeth with class I and II cavities. Methods: Searches: 1) for the assessment of existing systematic reviews: Electronic searches were conducted of OVID Medline, OVID Embase, The Cochrane Database of Systematic Reviews (CDSR), the Centre for Reviews and Dissemination (CRD) databases (DARE, NHSEED and HTA), Google Scholar, and the CNKI and CAOD Chinese databases; 2) for the systematic reviews of ART in permanent teeth: the above searches were supplemented by searches of the Cochrane Central Register of Controlled Trials (CENTRAL), LILAC, BBO, IMEAR (WHO Index Medicus for South East Region), WPRIM (WHO Western Pacific Region Index Medicus) and IndMed, Current Controlled Trials, Clinical Trials, OpenSIGLE, IADR conference abstracts and NLM Gateway. Hand searches were conducted of six dental journals known to have reported ART studies. References from retrieved systematic reviews, trials and other related papers were searched for additional reports. Authors were contacted. There were no language restrictions. Selection criteria: 1) for the assessment of existing systematic reviews: systematic reviews that compared ART to conventional treatment for the restoration of dental cavities; 2) for the systematic reviews of ART in permanent teeth: randomised controlled trials that compared ART using any adhesive material to conventional treatment using amalgam or any adhesive material Data collection: 1) for the assessment of existing systematic reviews: Reviews were selected and data was extracted by a single reviewer using a custom made data extraction sheet. Scope was assessed in terms of materials used, teeth and cavity type. Methodological quality was assessed using AMSTAR. Reporting quality was assessed using the PRISMA guidelines; 2) for the systematic reviews of ART in permanent teeth: reports of trials were screened and selected independently by two reviewers and data would have been extracted on a custom made data extraction sheet had there been eligible trials. Results: 1) for the assessment of existing systematic reviews: three systematic reviews were identified. Two of these were restricted to comparing ART with glass-ionomer to conventional treatment with amalgam; two allowed for inclusion of all cavity types in both deciduous and permanent teeth. None was of high methodological quality and reporting quality was good in one of the reviews only; 2) for the systematic reviews of ART in permanent teeth: no eligible trials were identified. Author’s conclusions: 1) existing systematic reviews do not have sufficient scope to allow for the inclusion of potentially eligible trials that would assess ARTs effectiveness and they have been of high to medium risk of bias; 2) it is disappointing that there are no properly conducted randomised controlled trials comparing ART to conventional treatment in class I and II cavities in the permanent dentition.