Glass ionomer ART restorations in deciduous teeth may perform comparably to traditional amalgam restorations
ANALYSIS & EVALUATION
Taifour D, Frencken JE, Beiruti N, van ‘t Hof, Truin GJ. Effectiveness of glass-ionomer (ART) and amalgam restorations in the deciduous dentition: Results after 3 years. Caries Res 2002;36:437-44.
Level of Evidence
To assess the survival of glass-ionomer restorations in deciduous teeth in comparison with traditional restorations using amalgam
The Government of the Netherlands, Dental Health International Netherlands (NGO), GC Europe, and 3MESPE
Source of Funding
Randomized controlled trial
Type of Study/Design
Summary SUBJECTS A total of 835 Syrian children aged 6 to 7 years participated in the study. Through random allocation, 482 were treated through the atraumatic restorative treatment (ART) approach and 353 were treated with amalgam restorations (MTA). In deciduous molar teeth, 476 single-surface and 610 multiple-surface ART restorations were placed compared with 380 and 425 amalgams, respectively. There was no statistically significant difference with respect to restorations placed per child, percentage of multiple-surface restorations, and sex.
J Evid Base Dent Pract 2003;3:137-8 © 2003 Mosby, Inc. All rights reserved. doi:10.1067/med.2003.49
TREATMENT ART restorations involved only the use of hand instruments. The dentine cavity was opened with a dental hatchet, the soft carious dentine was removed with excavators, and the resultant cavity and adjacent pits and fissures were filled with a high-viscosity glass ionomer restorative material. Isolation was achieved through the use of cotton wool rolls. Amalgam restorations (MTA) involved the removal of caries and creation of retention by using drills. Nongamma 2 amalgam was used for the restorations. Suction and cotton wool rolls were used for isolation. Treatment was provided by 8 dentists. Local anesthesia was rarely used in either treatment group. MAIN OUTCOME MEASURE Modified ART criteria1 were used to assess outcomes according to success or failure of the restorations. Fail137
ure was assessed as the presence of a deficiency at the cavity margin of ≥0.5 mm, overextension of the approximal margin of ≥0.5 mm, a fracture in the restoration, or a missing restoration. The evaluations were undertaken by the same 3 examiners at years 1 and 2, and by 1 original and 1 new examiner for year 3.
MAIN RESULTS Loss of subjects to follow-up was 10.6%, 28.8%, and 22.1% at 1-, 2-, and 3-years respectively. The 3-year cumulative survival percentages for ART and MTA were 86.1% and 79.6% respectively (P = .03). For multiple-surface restorations, the cumulative survival percentages at 3 years were 48.7% for ART and 42.9% for MTC (P > .05). The main reason for failure for both treatment groups was “restoration missing” followed by “fracture in restoration” for ART and “gross marginal defect” for MTA. The 3-year cumulative survival percentages for both single- and multiple-surface restorations varied considerably among the operators, with an operator effect for multiple-surface MTA restorations of P = .001.
Commentary CONCLUSIONS The authors concluded that over a 3-year period the ART approach with glass ionomer yielded better results in treating dentinal lesions in deciduous teeth than did the traditional approach with amalgam. The differences were, however, of borderline significance. In this study, which was part of the oral plan for improving the oral health of young Syrians, it was recommended that the ART approach be selected to compliment the other activities of the school oral health program. ANALYSIS This large randomized prospective clinical trial demonstrated that, in the study sample derived from a population with a high level of deciduous caries (dmft 5), overall ART performance was comparable to, if not slightly better than, amalgam treatment in deciduous molar teeth. The survival outcomes for ART were consistent with the outcomes of several other studies of deciduous teeth restored with high-viscosity glass ionomer that were carried out under different circumstances in different countries. The present study adds to a growing body of evidence validating the ART approach for the treatment of dentine caries. There were some minor deficiencies in the study, largely brought about by the problems of working in the 138 Taifour et al
field. For instance, the randomization process was not perfect since on some days electrical supply failure meant that only ART restorations could be performed on children allocated to the amalgam group. The authors, however, considered that in view of the large number of children treated in the study this should not have adversely biased the outcomes. In addition, these deficiencies highlight some of the problems of trying to undertake traditional dental care in developing countries. The only other discrepancy in the study was that at years 1 and 2 the evaluations were undertaken by the same 3 examiners. For the year-3 evaluation, only 1 of the original examiners was used and 1 new examiner was added. ART has been advocated as a patient-friendly approach, and studies have shown it to be very well accepted by children as young as 3.2,3 Unfortunately, this current study did not include this important aspect in its evaluation. Finally, this study remains the only study in which ART and amalgam restorations have been compared in a RCT. While the findings are extremely important and pertinent to the management of dentine caries in deciduous teeth, there remains a need for more comparative studies between ART and traditional treatment under different circumstances where, in addition to survival outcomes, issues such as cost effectiveness, patient acceptance, and operator acceptance are examined. REFERENCES 1. Frencken JE, Makoni F, Sithole D. A traumatic restorative treatment and glass-ionomer sealants in a school oral health programme in Zimbabwe; evaluation after one year. Caries Res 1996;30:428-33. 2. Lo ECM, Holmgren CJ. Provision of atraumatic restorative treatment (ART) restorations to Chinese pre-school children—a 30 month evaluation. Int J Paed Dent 2001;11:3-10. 3. van Amerongen WE. Rahimtoola S. Is ART really atraumatic? Community Dent Oral Epidemiol 1999;27:431-5.
Reviewer: Christopher J. Holmgren BDS, PhD, FDSRCS The University of Hong Kong
Comments from Philippe Hujoel, statistical reviewer: Inappropriate survival analysis methods were used to analyze the RCT. As a result, both the standard errors and the P values reported in this study were incorrect. The significant differences between ART and MTA are most likely spurious. Only a reanalysis of the data by using proper analytic methods will allow determination of the extent to which the P values and confidence intervals were biased.
Journal of Evidence-Based Dental Practice September 2003