Outcomes of silver-modified atraumatic restorative technique (SMART) in carious primary teeth: a systematic review and meta-analysis of randomised clinical studies

Background: This systematic review evaluated the outcomes of Silver Modified Atraumatic Restorative Treatment (SMART) in managing carious primary teeth. Methods: Following the International Prospective Register of Systematic Reviews (PROSPERO) registration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search of ten databases identified randomised clinical studies published in English from January 2010 to May 2025. Study selection, data extraction, and quality assessment were independently conducted, with the risk of bias assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) tool and evidence levels determined via the Oxford Centre for Evidence-Based Medicine (OCEBM) tool. Data analysis included single- and two-arm meta-analyses, sensitivity analysis, subgroup analysis, meta-regression, and evaluation of publication bias. Results: Nine studies published between 2022 and 2025 were included, with eight used for meta-analysis. Most of the included primary studies originated from Egypt (n = 6) and India (n = 3). Weighted mean success rates for SMART were 94.9% (Confidence Interval (CI): (90.7, 99.1)), 82.0% (CI: (71.0, 93.0)), and 69.5% (CI: (52.4, 86.6)) at 3-, 6-, and 12-month follow-ups, respectively. Funnel plots indicated slight asymmetry at 3 and 12 months, while the 6-month plot appeared relatively symmetrical. A two-arm meta-analysis found SMART achieved success rates comparable to Atraumatic Restorative Treatment (ART) at 6- and 12-month follow-ups (p > 0.05), with no significant data heterogeneity. Subgroup analysis revealed higher success rates when marginal adaptation was used as the evaluation criterion compared to pain or mobility (p < 0.05). Meta-regression indicated that sample size did not affect heterogeneity, and Egger’s test showed no publication bias was detected. Conclusions: Findings suggested that SMART appears to be an effective alternative for treating carious primary teeth, but further research is needed to standardise evaluation criteria and confirm long-term efficacy. The PROSPERO Registration: ID: CRD42023480630.

Atraumatic restorative treatment; Deciduous teeth; Dental caries; Dental materials; Silver diamine fluoride

[1] Gatón-Hernandéz P, Serrano CR, da Silva LAB, de Castañeda ER, da Silva RAB, Pucinelli CM, et al. Minimally interventive restorative care of teeth with molar incisor hypomineralization and open apex—a 24-month longitudinal study. International Journal of Paediatric Dentistry. 2020; 30: 4–10.

[2] Lin GSS, Chan DZK, Lee HY, Low TT, Laer TS, Pillai MPM, et al. Effectiveness of resin infiltration in caries inhibition and aesthetic appearance improvement of white-spot lesions: an umbrella review. Journal of Evidence-Based Dental Practice. 2022; 22: 101723.

[3] Ramos-Gomez FJ, Crystal YO, Domejean S, Featherstone JD. Minimal intervention dentistry: part 3. Paediatric dental care—prevention and management protocols using caries risk assessment for infants and young children. British Dental Journal. 2012; 213: 501–508.

[4] Ebrahimi M, Shirazi AS, Afshari E. Success and behavior during atraumatic restorative treatment, the Hall Technique, and the stainless steel crown technique for primary molar teeth. Pediatric Dentistry Journal. 2020; 42: 187–192.

[5] Lin GSS, Cher CY, Cheah KK, Koh SH, Chia CHL, Lim VR, et al. Acceptability of atraumatic restorative treatment and Hall Technique among children, parents, and general dental practitioners: a systematic review and meta-analysis. Quintessence International. 2022; 53: 156–169.

[6] Jiang M, Fan Y, Li KY, Lo ECM, Chu CH, Wong MCM. Factors affecting success rate of atraumatic restorative treatment (ART) restorations in children: a systematic review and meta-analysis. Journal of Dentistry. 2021; 104: 103526.

[7] Seifo N, Cassie H, Radford JR, Innes NPT. Silver diamine fluoride for managing carious lesions: an umbrella review. BMC Oral Health. 2019; 19: 145.

[8] Crystal YO, Marghalani AA, Ureles SD, Wright JT, Sulyanto R, Divaris K, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatric Dentistry Journal. 2017; 39: 135–145.

[9] Chu CH, Mei L, Seneviratne CJ, Lo EC. Effects of silver diamine fluoride on dentine carious lesions induced by Streptococcus mutans and Actinomyces naeslundii biofilms. International Journal of Paediatric Dentistry. 2012; 22: 2–10.

[10] Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries “silver-fluoride bullet”. Journal of Dental Research. 2009; 88: 116–125.

[11] Zhao IS, Gao SS, Hiraishi N, Burrow MF, Duangthip D, Mei ML, et al. Mechanisms of silver diamine fluoride on arresting caries: a literature review. International Dental Journal. 2018; 68: 67–76.

[12] Mubaraki H, Ingle NA, Baseer MA, AlMugeiren OM, Mubaraki S, Cicciù M, et al. Effect of silver diamine fluoride on bacterial biofilms-a review including in vitro and in vivo studies. Biomedicines. 2023; 11: 1641.

[13] Satyarup D, Mohanty S, Nagarajappa R, Mahapatra I, Dalai RP. Comparison of the effectiveness of 38% silver diamine fluoride and atraumatic restorative treatment for treating dental caries in a school setting: a randomized clinical trial. Dental and Medical Problems. 2022; 59: 217–223.

[14] Crystal YO, Kreider B, Raveis VH. Parental expressed concerns about Silver Diamine Fluoride (SDF) treatment. Journal of Clinical Pediatric Dentistry. 2019; 43: 155–160.

[15] Bansal K, Shamoo A, Mani K, K PD, Verma A, Mathur VP, et al. Silver diamine fluoride modified atraumatic restorative treatment compared to conventional restorative technique on carious primary molars—a randomized controlled trial. Journal of Dentistry. 2023; 138: 104698.

[16] Aly AAM, Aziz AMA, Elghazawy RK, El Fadl RKA. Survival analysis and cost effectiveness of Silver Modified Atraumatic Restorative Treatment (SMART) and ART occlusal restorations in primary molars: a randomized controlled trial. Journal of Dentistry. 2023; 128: 104379.

[17] Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. The BMJ. 2021; 372: n71.

[18] Higgins JPT, Sterne JAC, Savović J, Page MJ, Hróbjartsson A, Boutron I, et al. A revised tool for assessing risk of bias in randomized trials. Cochrane Database of Systematic Reviews. 2016; Suppl 1: 29–31.

[19] Oxford Centre for Evidence-Based Medicine, OCEBM Levels of Evidence Working Group. The oxford levels of evidence 2. 2011. Available at: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence (Accessed: 01 June 2025).

[20] Lin GSS, Hisham ARB, Cher CY, Cheah KK, Ghani NRNA, Noorani TY. Success rates of coronal and partial pulpotomies in mature permanent molars: a systematic review and single-arm meta-analysis. Quintessence International. 2021; 52: 196–208.

[21] Mohammed SME, 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. The Journal of Contemporary Dental Practice. 2022; 23: 1140–1145.

[22] Ahmad M, Khattab N, Amer M. Radiographic assessment of silver modified atraumatic restorative technique in comparison to atraumatic restorative technique. Egyptian Dental Journal. 2022; 68: 1183–1190.

[23] Rady M, Sabbah A. A 24-month clinical assessment of active dentin caries arresting by silver diamine fluoride in primary molars: a randomized clinical trial. Egyptian Dental Journal. 2023; 69: 899–910.

[24] Abdelhamid MS, El Tawil SB, Moheb DM. Clinical and radiographic evaluation after the use of silver modified atraumatic restorative treatment versus atraumatic restorative treatment in the management of occlusal caries of primary molars in preschool children: a randomized clinical trial. Cuestiones de Fisioterapia. 2025; 54: 1600–1617.

[25] Patel MC, Makwani DA, Bhatt RK, Raj V, Patel C, Patel F. Evaluation of silver-modified atraumatic restorative technique versus conventional pulp therapy in asymptomatic deep carious lesion of primary molars—a comparative prospective clinical study. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2022; 40: 383–390.

[26] Sharawat N, Bansal K, Mathur VP, Tewari N, Morankar R, Mishra R. Evaluation of the success of single-visit versus two-visit silver modified atraumatic restorative technique (SMART) in primary molars—a randomized controlled trial. Journal of Dentistry. 2025; 156: 105661.

[27] Shawki SA, Al-Bauomy SY, Mostafa MH. Clinical and radiographic outcomes of two biological approaches versus the conventional one for management of dental caries in primary teeth. Al-Azhar Journal of Dental Science for Girls. 2023; 10: 217–226.

[28] Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977; 33: 159–174.

[29] Surendranath P, Krishnappa S, Srinath S. Silver diamine fluoride in preventing caries: a review of current trends. International Journal of Clinical Pediatric Dentistry. 2022; 15: S247–S251.

[30] Chibinski AC, Wambier LM, Feltrin J, Loguercio AD, Wambier DS, Reis A. Silver diamine fluoride has efficacy in controlling caries progression in primary teeth: a systematic review and meta-analysis. Caries Research. 2017; 51: 527–541.

[31] Nica I, Stoleriu S, Iovan A, Tărăboanță I, Pancu G, Tofan N, et al. Conventional and resin-modified glass ionomer cement surface characteristics after acidic challenges. Biomedicines. 2022; 10: 1755.

[32] Alsari A, Ghilotti J, Sanz JL, Liena C, Folguera S, Melo M. Comparative evaluation of the microleakage of glass ionomers as restorative materials: a systematic review of in vitro studies. Applied Sciences. 2024; 14: 1729.

[33] Osama S, Badran AS, Awad BG. Effect of silver diamine fluoride on the microleakage of flowable resin composite and glass ionomer cement restorations to carious primary dentin: an-in vitro study. BMC Oral Health. 2024; 24: 91.

[34] Jiang M, Mei ML, Wong MCM, Chu CH, Lo ECM. Effect of silver diamine fluoride solution application on the bond strength of dentine to adhesives and to glass ionomer cements: a systematic review. BMC Oral Health. 2020; 20: 40.

[35] Rinsathon J, Wiriyasuebpong S, Thariya K, Jiradechochai P, Phetsuk P, Bouanil S, et al. Bonding performance of glass ionomer cement to carious dentin treated with different surface treatment protocols using silver diamine fluoride. Scientific Reports. 2023; 13: 14233.

[36] Kitsaras G, Goodwin M, Kelly MP, Pretty IA. Bedtime oral hygiene behaviours, dietary habits and children’s dental health. Children. 2021; 8: 416.

[37] Ebaya MM, Ali AI, Mahmoud SH. Evaluation of marginal adaptation and microleakage of three glass ionomer-based class V restorations: in vitro study. European Journal of Dentistry. 2019; 13: 599–606.

[38] Albelasy EH, Hamama HH, Chew HP, Montaser M, Mahmoud SH. Secondary caries and marginal adaptation of ion-releasing versus resin composite restorations: a systematic review and meta-analysis of randomized clinical trials. Scientific Reports. 2022; 12: 19244.

[39] Nagarwal P, Rana V, Srivastava N, Kaushik N, Pruthi T. Reliability of three pain assessment tools in children requiring dental treatment: a comparative clinical study. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2023; 41: 126–132.

[40] Dixon LJ, Linardon J. A systematic review and meta-analysis of dropout rates from dialectical behaviour therapy in randomized controlled trials. Cognitive and Behavioral Practice. 2020; 49: 181–196.

[41] Cramer H, Haller H, Dobos G, Lauche R. A systematic review and meta-analysis estimating the expected dropout rates in randomized controlled trials on yoga interventions. Evidence-Based Complementary and Alternative Medicine. 2016; 2016: 5859729.

[42] McCoy CE. Understanding the intention-to-treat principle in randomized controlled trials. The Western Journal of Emergency Medicine. 2017; 18: 1075–1078.

[43] Gupta SK. Intention-to-treat concept: a review. Perspectives in Clinical Research. 2011; 2: 109–112.

[44] Fa BA, Jew JA, Wong A, Young D. Silver modified atraumatic restorative technique (SMART): an alternative caries prevention tool. The Stomatology Edu Journal. 2016; 3: 243–249.

[45] Oliveira GL, Carvalho CN, Carvalho EM, Bauer J, Leal AMA. The influence of mixing methods on the compressive strength and fluoride release of conventional and resin-modified glass ionomer cements. International Journal of Dentistry. 2019; 2019: 6834931.