The Journal of Contemporary Dental Practice

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 23 , ISSUE 11 ( November, 2022 ) > List of Articles


Comparison of Clinical Outcomes of Silver-modified Atraumatic Restorative Technique vs Atraumatic Restorative Technique in Primary Teeth: A Randomized Controlled Trial

Sahar Mohammed ElHassanien Mohammed, Salwa Mohammad Awad, Ahmed Hamdy Wahba

Keywords : Atraumatic restorative technique, Randomized clinical trial, Silver diamine fluoride, Silver-modified atraumatic restorative technique

Citation Information : Mohammed SM, Awad SM, Wahba AH. Comparison of Clinical Outcomes of Silver-modified Atraumatic Restorative Technique vs Atraumatic Restorative Technique in Primary Teeth: A Randomized Controlled Trial. J Contemp Dent Pract 2022; 23 (11):1140-1145.

DOI: 10.5005/jp-journals-10024-3437

License: CC BY-NC 4.0

Published Online: 17-03-2023

Copyright Statement:  Copyright © 2022; The Author(s).


Aim: To compare the clinical outcomes of silver-modified atraumatic restorative technique (SMART) vs atraumatic restorative technique (ART) in primary teeth. Materials and methods: This study was a randomized clinical trial conducted on 30 children. The study was split-mouth design, so each group was consisted of 30 children. Children aged 3–6 years old of both genders. Communication with the children was established. Gross debris from cavitation was removed. Carious dentin on walls was excavated using spoon excavator and low-speed contra with round or fissure bur. The areas to be treated were isolated with cotton rolls. For ART, glass ionomer cement (GIC) was applied according to the manufacturer's instructions. For silver-modified atraumatic restorative technique (SMART), a protective coating was applied to the lips and skin to prevent a temporary tattoo. Silver diamine fluoride (SDF) was applied carefully using bended microsponge brush. It was applied directly to only the affected tooth surface. The lesion was dried for 15 seconds with gentle flow of compressed air. After 1 week, GIC was applied according to the manufacturer's instructions. Clinical evaluation was done for all teeth at 6 and 12 months. The data were collected and then statistically analyzed using the Chi-square test to show the difference between groups. Results: The restoration of the first primary molar with ART restoration alone showed a lower success rate when compared with the restoration with a combination of SDF and ART (SMART technique), with percentages of 70% and 76.67% and 53.33% and 60% after 6 months and 12 months of follow-up, respectively. Conclusion: Silver diamine fluoride is successful in arresting dentin caries and can be used to increase the efficacy of the ART technique in primary teeth. Clinical significance: It is recommended to use SDF as a noninvasive approach to control dentin caries with the ART technique.

  1. Abou El Fadl R, Abdel Fattah M, Ezz M. Assessing the prevalence of early childhood caries and the associated determinants in a group of preschool children: Results from a national oral health survey in Egypt. Egyptian Dent J 2019;65:31–39.
  2. Chen KJ, Duangthip D, Gao SS, et al. Oral health policies to tackle the burden of early childhood caries: A review of 14 countries/regions. Front Oral Health 2021;2:670154. DOI: 10.3389/froh.2021.670154
  3. Duangthip D, Jiang M, Chu CH, et al. Non-surgical treatment of dentin caries in preschool children – systematic review. BMC Oral Health 2015;15:44–52. DOI: 10.1186/s12903-015-0033-7.
  4. Dye BA, Hsu K-LC, Afful J. Prevalence and measurement of dental caries in young children. Pediatr Dent 2015;37(3):200–216. PMID: 26063550
  5. Yee R, Holmgren C, Mulder J, et al. Efficacy of silver diamine fluoride for arresting caries treatment. J Dent Res 2009;88(7):644–647. DOI: 10.1177/0022034509338671.
  6. Meyer BD, Lee JY, Lampiris LN, et al. They told me to take him somewhere else: Caregivers’ experiences seeking emergency dental care for their children. Pediatr Dent 2017;39(3):209–214. PMID: 28583245
  7. Innes NPT, Chu CH, Fontana M, et al. A century of change towards prevention and minimal intervention in cariology. J Dent Res 2019;98(6):611–617. DOI: 10.1177/0022034519837252.
  8. Kearns CE, Glantz SA, Schmidt LA. Sugar industry influence on the scientific agenda of the National Institute of Dental Research's 1971 National Caries Program: A historical analysis of internal documents. PLoS Med 2015;12(3):e1001798. DOI: 10.1371/journal.pmed.1001798
  9. Duangthip D, Chen K, Gao S, et al. Managing early childhood caries with atraumatic restorative treatment and topical silver and fluoride agents. Int J Environ Res Public Health 2017;14(10):1204. DOI: 10.3390/ijerph14101204.
  10. Nuvvula S, Mallineni SK. Silver diamine fluoride in pediatric dentistry. J South Asian Assoc Pediatr Dent 2019;2(2):73–80. DOI: 10.36348/sjodr.2022.v07i12.006
  11. Sarvas EW. Medical Management of Dental Caries. Dental Care for Children with Special Needs: Springer International Publishing; 2019. pp. 195–214.
  12. Schwendicke F, Frencken JE, Bjørndal L, et al. Managing carious lesions. Adv Dent Res 2016;28(2):58–67. DOI: 10.1177/0022034516639271
  13. Holmgren CJ, Roux D, Doméjean S. Minimal intervention dentistry: Part 5. Atraumatic restorative treatment (ART) – A minimum intervention and minimally invasive approach for the management of dental caries. Br Dent J 2013;214(1):11–18. DOI: 10.1038/sj.bdj.2012.1175.
  14. de Amorim RG, Leal SC, Frencken JE. Survival of atraumatic restorative treatment (ART) sealants and restorations: A meta-analysis. Clin Oral Investig 2012;16(2):429–441. DOI: 10.1007/s00784-011-0513-3.
  15. Horst JA, Ellenikiotis H, Milgrom PM, et al. UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications, and consent. J Calif Dent Assoc 2016;44(1):16–28. PMID: 26897901
  16. Quock RL, Barros JA, Yang SW, et al. Effect of silver diamine fluoride on microtensile bond strength to dentin. Oper Dent 2012;37(6):610–616. DOI: 10.2341/11-344-L.
  17. Crystal YO, Niederman R. Evidence-based dentistry update on silver diamine fluoride. Dent Clin North Am 2019;63(1):45–68. DOI: 10.1016/j.cden.2018.08.011.
  18. dos Santos APP, Nadanovsky P, de Oliveira BH. A systematic review and meta-analysis of the effects of fluoride toothpastes on the prevention of dental caries in the primary dentition of preschool children. Community Dent Oral Epidemiol 2012;41: 1–12. DOI: 10.1111/j.1600-0528.2012.00708.x.
  19. American Academy of Pediatric Dentistry. Policy on interim therapeutic restorations (ITR). The Reference Manual of Pediatric Dentistry. Chicago, III: American Academy of Pediatric Dentistry. 2020:72–73.
  20. Vollú AL, Rodrigues GF, Rougemount Teixeira RV, et al. Efficacy of 30% silver diamine fluoride compared to atraumatic restorative treatment on dentine caries arrestment in primary molars of preschool children: A 12-months parallel randomized controlled clinical trial. J Dent 2019;88:103165. DOI: 10.1016/j.jdent.2019.07.003.
  21. Wakhloo T, Reddy SG, Sharma SK, et al. Silver diamine fluoride vs atraumatic restorative treatment in pediatric dental caries management: A systematic review and meta-analysis. J Int Soc Prev Commun Dent 2021;11(4):367–375. DOI: 10.4103/jispcd.JISPCD_83_21
  22. Pandis N, Walsh T, Polychronopoulou A, et al. Split-mouth designs in orthodontics: An overview with applications to orthodontic clinical trials. Eur J Orthod 2013;35(6):783–789. DOI: 10.1093/ejo/cjs108.
  23. Frencken JE. Atraumatic restorative treatment and minimal intervention dentistry. Br Dent J 2017;223(3):183–189. DOI: 10.1038/sj.bdj.2017.664.
  24. Frencken JE, Leal SC, Navarro MF. Twenty-five-year atraumatic restorative treatment (ART) approach: A comprehensive overview. Clin Oral Investig 2012;16(5):1337–1346. DOI: 10.1007/s00784-012-0783-4.
  25. Frencken JE. The ART approach using glass-ionomers in relation to global oral health care. Dent Mater 2010;26(1):1–6. DOI: 10.1016/
  26. Bonifácio CC, Hesse D, Raggio DP, et al. The effect of GIC-brand on the survival rate of proximal-art restorations. Int J Paediatr Dent 2012;23:251–258. DOI: 10.1111/j.1365-263X.2012.01259.x.
  27. van't Hof MA, Frencken JE, Helderman WHvP, et al. The Atraumatic Restorative Treatment (ART) approach for managing dental caries: A meta-analysis. Int Dent J 2006;56(6):345–351.
  28. Mickenautsch S, Yengopal V, Banerjee A. Atraumatic restorative treatment vs amalgam restoration longevity: A systematic review. Clin Oral Investig 2010;14(3):233–240. DOI: 10.1007/s00784-009-0335-8.
  29. Thompson VT, Craig RG, Curro FA, et al. Treatment of deep carious lesions by complete excavation or partial removal. J Am Dent Assoc 2008;139(6):705–712. DOI: 10.14219/jada.archive.2008.0252.
  30. Tyas MJ. Placement and replacement of restorations by selected practitioners. Aust Dent J 2005;50(2):81–89. DOI: 10.1111/j.1834-7819.2005.tb00345.x.
  31. Mei ML, Nudelman F, Marzec B, et al. Formation of fluorohydroxyapatite with silver diamine fluoride. J Dent Res 2017;96(10):1122–1128. DOI: 10.1177/0022034517709738.
  32. Mei ML, Chu CH, Low KH, et al. Caries arresting effect of silver diamine fluoride on dentine carious lesion with S. mutans and L. acidophilus dual-species cariogenic biofilm. Med Oral Patol Oral Cir Bucal 2013;18(6):e824–e831. DOI: 10.4317/medoral.18831
  33. Fa BA, Jew JA, Wong A, et al. Silver modified atraumatic restorative technique (SMART): An alternative caries prevention tool. Stomatol EDU J 2016;3:243–249.
  34. Duffn S, Juhl J, Schwab S, et al. SMART Oral Health: The medical management of caries. Available online at; 2019.
  35. Puwanawiroj A, Trairatvorakul C, Dasanayake AP, et al. Microtensile bond strength between glass ionomer cement and silver diamine fluoride-treated carious primary dentin. Pediatric Dent 2018;40(4):291–295. PMID: 30345969
  36. Kidd EAM. Clinical threshold for carious tissue removal. DentClinNorth Am 2010;54(3):541–549. DOI: 10.1016/j.cden.2010.03.001
  37. Tantbirojn D, Feigal RJ, Ko C-C, et al. Remineralized dentin lesions induced by glass ionomer demonstrate increased resistance to subsequent acid challenge. Quintessence Int 2006;37(4):273–281. PMID: 16594358
  38. Fung MHT, Duangthip D, Wong MCM, et al. Randomized clinical trial of 12% and 38% silver diamine fluoride treatment. J Dent Res 2018;97(2):171–178. DOI: 10.1177/0022034517728496
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.