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Study flow diagram
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Figure 1

Study flow diagram

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Forest plot of comparison 1. Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC, outcome: 1.1 restoration failure (primary teeth) ‐ longest follow‐up
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Figure 4

Forest plot of comparison 1. Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC, outcome: 1.1 restoration failure (primary teeth) ‐ longest follow‐up

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Comparison 1 Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC, Outcome 1 Restoration failure ‐ primary teeth ‐ longest follow‐up.
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Analysis 1.1

Comparison 1 Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC, Outcome 1 Restoration failure ‐ primary teeth ‐ longest follow‐up.

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Comparison 1 Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC, Outcome 2 Pain ‐ primary teeth.
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Analysis 1.2

Comparison 1 Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC, Outcome 2 Pain ‐ primary teeth.

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Comparison 1 Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC, Outcome 3 Participant experience ‐ discomfort.
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Analysis 1.3

Comparison 1 Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC, Outcome 3 Participant experience ‐ discomfort.

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Comparison 2 Atraumatic restorative treatment using composite versus conventional treatment using composite, Outcome 1 Restoration failure ‐ primary teeth ‐ longest follow‐up.
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Analysis 2.1

Comparison 2 Atraumatic restorative treatment using composite versus conventional treatment using composite, Outcome 1 Restoration failure ‐ primary teeth ‐ longest follow‐up.

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Comparison 2 Atraumatic restorative treatment using composite versus conventional treatment using composite, Outcome 2 Participant experience ‐ dental anxiety.
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Analysis 2.2

Comparison 2 Atraumatic restorative treatment using composite versus conventional treatment using composite, Outcome 2 Participant experience ‐ dental anxiety.

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Comparison 3 Atraumatic restorative treatment using resin‐modified glass ionomer cement (RM‐GIC) versus conventional treatment using RM‐GIC, Outcome 1 Restoration failure ‐ permanent teeth ‐ longest follow‐up.
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Analysis 3.1

Comparison 3 Atraumatic restorative treatment using resin‐modified glass ionomer cement (RM‐GIC) versus conventional treatment using RM‐GIC, Outcome 1 Restoration failure ‐ permanent teeth ‐ longest follow‐up.

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Comparison 3 Atraumatic restorative treatment using resin‐modified glass ionomer cement (RM‐GIC) versus conventional treatment using RM‐GIC, Outcome 2 Secondary caries.
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Analysis 3.2

Comparison 3 Atraumatic restorative treatment using resin‐modified glass ionomer cement (RM‐GIC) versus conventional treatment using RM‐GIC, Outcome 2 Secondary caries.

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Summary of findings for the main comparison. Atraumatic restorative treatment (ART) using high‐viscosity glass ionomer cement (H‐GIC) compared with conventional restorative treatment using H‐GIC for dental caries

Atraumatic restorative treatment (ART) using high‐viscosity glass ionomer cement (H‐GIC) compared with conventional restorative treatment using H‐GIC for dental caries

Patient or population: people with dental caries

Settings: community settings and dental clinics

Intervention: ART using H‐GIC

Comparison: conventional treatment using H‐GIC

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Conventional treatment with H‐GIC

ART with H‐GIC

Restoration failure (primary dentition)

at 12 to 24 months

471 per 1000

588 per 1000
(502 to 669)

OR 1.60
(1.13 to 2.27)

643 participants/846 teeth
(5 studies)

⊕⊕⊝⊝
low1

Pain

Mean pain (primary teeth) was 1.38 (SD 1.21)

Mean pain (primary teeth) was 0.73 (SD 1.14)

MD 0.65 lower (1.38 lower to 0.07 higher)

40 participants
(1 study)

⊕⊕⊝⊝
low2

Adverse events

‐

‐

‐

‐

Not measured

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; OR: odds ratio

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

1We downgraded the evidence by two levels because of very serious concerns regarding risk of bias: we judged all five studies as high risk of performance bias, three studies as high risk of attrition bias, and two studies as high risk of reporting bias.
2We downgraded the evidence by one level because it is a single study (imprecision) and one level because of serious concern regarding high risk of performance bias.

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Summary of findings for the main comparison. Atraumatic restorative treatment (ART) using high‐viscosity glass ionomer cement (H‐GIC) compared with conventional restorative treatment using H‐GIC for dental caries
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Summary of findings 2. Atraumatic restorative treatment (ART) using composite resins compared with conventional restorative treatment using composite resins for dental caries

Atraumatic restorative treatment (ART) using composite resins compared with conventional restorative treatment using composite resins for dental caries

Patient or population: people with dental caries

Settings: community settings and dental clinics

Intervention: ART using composite

Comparison: conventional treatment using composite

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Conventional treatment

ART

Restoration failure (primary dentition)

362 per 1000

387 per 1000
(235 to 565)

OR 1.11
(0.54 to 2.29)

57 participants/100 teeth
(1 study)

⊕⊝⊝⊝
very low1

Pain

‐

‐

‐

‐

Not measured

Adverse events

‐

‐

‐

‐

Not measured

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

1We downgraded the evidence by three levels: one level because it is a single study (indirectness) and two levels because of very serious concern regarding the risk of bias (high risk of performance bias and high risk of attrition bias). The result was also very imprecise.

Figuras y tablas -
Summary of findings 2. Atraumatic restorative treatment (ART) using composite resins compared with conventional restorative treatment using composite resins for dental caries
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Summary of findings 3. Atraumatic restorative treatment (ART) using resin‐modified glass ionomer cement (RM‐GIC) compared with conventional restorative treatment using RM‐GIC for dental caries

Atraumatic restorative treatment (ART) using resin‐modified glass ionomer cement (RM‐GIC) compared with conventional restorative treatment using RM‐GIC for dental caries

Patient or population: people with dental caries

Settings: community settings and dental clinics

Intervention: ART using RM‐GIC

Comparison: conventional treatment using RM‐GIC

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Conventional treatment

ART

Restoration failure (primary dentition)

‐

‐

‐

0 studies

No studies included

Restoration failure (permanent teeth)

75 per 1000

180 per 1000
(71 to 388)

OR 2.71
(0.94 to 7.81)

64 participants/141 teeth
(1 study)

⊕⊝⊝⊝
very low1

Pain

‐

‐

‐

‐

Not measured

Adverse events

‐

‐

‐

‐

Not measured

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

1We downgraded the evidence by one level because it is a single study (indirectness), one level because of concern regarding high risk of performance bias, and one level because the result was imprecise.

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Summary of findings 3. Atraumatic restorative treatment (ART) using resin‐modified glass ionomer cement (RM‐GIC) compared with conventional restorative treatment using RM‐GIC for dental caries
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Table 1. ART versus conventional treatment studies using different materials in each arm

ART with one material versus conventional treatment with another material

ART material

Conventional treatment material

Outcomes

Effect estimate

OR

(95% CI)

H‐GIC

Amalgam

Restoration failure ‐primary teeth – 2 studies (Miranda 2005; Yu 2004). Studies reporting on single + multiple lesions

2.15 (0.73 to 6.35); I2 = 0%

Pain (primary dentition) – 1 study (Miranda 2005). Studies reporting on single + multiple lesions

1.44 (0.45 to 4.60)

GIC

Amalgam

Restoration failure ‐ primary teeth – 1 study (Ling 2003). Studies reporting on lesion type: not reported

0.78 (0.30 to 2.02)

Restoration failure ‐ permanent, immature teeth – 1 study (Estupiñan‐Day 2006). Studies reporting on lesion type: not reported

1.71 (1.32 to 2.22)

Pain ‐ permanent, immature teeth (Estupiñan‐Day 2006)

0.41 (0.35 to 0.47)

H‐GIC

Composite and local anaesthetic

Restoration failure ‐ primary teeth – 1 study (Luz 2012). Studies reporting on multiple lesions

8.00 (1.24 to 51.48)

Pain (primary dentition) – 1 study (Luz 2012)

2.22 (0.51 to 9.61)

H‐GIC

RM‐GIC and local anaesthetic

Restoration failure ‐ permanent, mature teeth – 2 studies (Da Mata 2015; Lo 2006). Studies reporting on coronal/root caries

1.46 (0.74 to 2.88); I2 = 0%

CI: confidence interval; OR: odds ratio

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Table 1. ART versus conventional treatment studies using different materials in each arm
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Comparison 1. Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Restoration failure ‐ primary teeth ‐ longest follow‐up Show forest plot

5

Odds Ratio (Random, 95% CI)

1.60 [1.13, 2.27]

1.1 Single and multiple cavity surfaces

1

Odds Ratio (Random, 95% CI)

2.75 [0.50, 15.16]

1.2 Multiple cavity surfaces

3

Odds Ratio (Random, 95% CI)

1.62 [1.03, 2.55]

1.3 Type of cavity surfaces not reported

1

Odds Ratio (Random, 95% CI)

0.79 [0.12, 5.45]

2 Pain ‐ primary teeth Show forest plot

1

40

Mean Difference (IV, Fixed, 95% CI)

‐0.65 [‐1.38, 0.07]

3 Participant experience ‐ discomfort Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected
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Comparison 1. Atraumatic restorative treatment using high‐viscosity glass ionomer cement (H‐GIC) versus conventional treatment using H‐GIC
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Comparison 2. Atraumatic restorative treatment using composite versus conventional treatment using composite

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Restoration failure ‐ primary teeth ‐ longest follow‐up Show forest plot

1

Odds Ratio (Random, 95% CI)

Totals not selected

2 Participant experience ‐ dental anxiety Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
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Comparison 2. Atraumatic restorative treatment using composite versus conventional treatment using composite
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Comparison 3. Atraumatic restorative treatment using resin‐modified glass ionomer cement (RM‐GIC) versus conventional treatment using RM‐GIC

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Restoration failure ‐ permanent teeth ‐ longest follow‐up Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Totals not selected

2 Secondary caries Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Subtotals only
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Comparison 3. Atraumatic restorative treatment using resin‐modified glass ionomer cement (RM‐GIC) versus conventional treatment using RM‐GIC
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