Dental caries remains the most prevalent chronic disease in children worldwide, disproportionately affecting populations with limited access to conventional dental care [1]. Early childhood caries frequently involves primary molars, leading to pain, infection, and impaired quality of life if left untreated [2]. Conventional restorative treatment using rotary instrumentation and resin-based materials remains the standard of care; however, the requirement for electrically driven equipment, local anesthesia, and patient cooperation often limits its feasibility in young children and community-based programs [3]. Atraumatic restorative treatment (ART) was introduced as a minimally invasive technique employing hand instruments for caries removal and high-viscosity glass ionomer cement for restoration [4]. ART preserves sound tooth structure, reduces treatment-associated anxiety, and eliminates the need for rotary devices [5]. Over the past decade, ART has gained acceptance within pediatric and public health dentistry, particularly in low-resource environments [6]. Glass ionomer materials used in ART exhibit chemical adhesion to enamel and dentin, fluoride release, and favorable biocompatibility, which collectively contribute to caries-preventive effects [7]. However, concerns remain regarding restoration longevity, wear resistance, and marginal integrity compared with resin composite restorations placed following conventional cavity preparation [8]. Several randomized clinical trials and systematic reviews conducted in recent years have evaluated ART performance in primary teeth. Bonifácio et al. reported comparable survival of ART and conventional restorations at two years in primary molars [9]. Similarly, Schwendicke and Frencken’s meta-analysis demonstrated no significant difference in restoration survival between ART and conventional methods in short-term follow-up [10]. Yet, variations in study design, operator experience, and evaluation criteria necessitate further well-controlled clinical investigations. Understanding the relative success of ART versus conventional restorations is critical for evidence-based treatment planning, particularly in pediatric dentistry where cooperation, anxiety control, and chair-side efficiency are major considerations [11]. Moreover, post-pandemic shifts toward minimally aerosol-generating procedures have further renewed interest in ART as a safer clinical alternative [12]. Therefore, the present study aimed to conduct a randomized clinical evaluation comparing the one-year success of ART and conventional restorations in primary molars, assessing restoration survival, marginal adaptation, secondary caries, and patient-reported comfort outcomes.

Study design and ethical approval A randomized parallel-group clinical trial was conducted in the Department of Pediatric Dentistry of a university dental hospital between January 2023 and March 2024. Ethical approval was obtained from the Institutional Ethics Committee (IEC/PD/2023/017). Written informed consent was secured from parents or guardians. Sample selection Children aged 5–8 years presenting with at least one primary molar exhibiting occlusal or occlusoproximal dentinal caries were screened. Teeth with pulpal involvement, abscess, or mobility were excluded. A total of 120 teeth from 68 children were included. Sample size was calculated assuming 85% expected ART success based on prior literature [9], power 80%, and alpha 0.05. Randomization and allocation Teeth were randomly allocated using computer-generated block randomization into: • Group A (ART): Hand excavation and restoration with high-viscosity glass ionomer cement. • Group B (Conventional): Rotary cavity preparation and resin composite restoration. Allocation concealment was ensured using sealed opaque envelopes. Operative procedures ART group: Caries removal was performed using spoon excavators under cotton roll isolation. High-viscosity glass ionomer cement (Fuji IX GP Extra, GC Corp.) was mixed according to manufacturer instructions and pressed into the cavity using finger-press technique. Occlusion was checked, and petroleum jelly applied for surface protection. Conventional group: Local anesthesia was administered when required. Caries removal and cavity preparation were performed using high-speed burs under water coolant. Acid etching, bonding, and resin composite placement were performed incrementally and light-cured. Finishing and polishing were completed. Outcome assessment Two blinded calibrated examiners evaluated restorations at 6 and 12 months using modified USPHS criteria assessing: • Restoration retention • Marginal integrity • Secondary caries • Postoperative sensitivity Chair-side treatment time was recorded using a stopwatch. Child discomfort was measured using the Wong-Baker FACES scale. Statistical analysis Data were analyzed using SPSS v26. Chi-square test compared categorical outcomes, and independent t-test compared mean chair-side time and discomfort scores. Significance was set at p<0.05.

Table 1. Baseline characteristics of study participants Parameter ART Group (n=60) Conventional Group (n=60) p-value Mean age (years) 6.4 ±1.1 6.6 ±1.0 0.42 Male/Female 31/29 33/27 0.71 Occlusal lesions 38 36 0.68 Occlusoproximal lesions 22 24 0.74 Narrative: Both groups were comparable regarding age, gender distribution, and lesion type (p>0.05), indicating successful randomization. This ensured baseline equivalence between ART and conventional treatment groups for unbiased outcome comparison. Table 2. Chair-side treatment time Group Mean Time (minutes) SD p-value ART 6.4 ±1.2 <0.001 Conventional 11.2 ±2.0 Narrative: ART required significantly less operative time than conventional restorations (p<0.001). Reduced chair-side time contributed to improved child cooperation and minimized clinical fatigue. Table 3. Restoration success at 6 months Outcome ART (%) Conventional (%) p-value Successful restorations 93.3 95.0 0.64 Marginal defects 3.3 2.0 0.65 Secondary caries 3.4 3.0 0.88 Narrative: At 6 months, both groups demonstrated high restoration survival with no statistically significant differences in retention or secondary caries development. Table 4. Restoration success at 12 months Outcome ART (%) Conventional (%) p-value Successful restorations 88.3 92.5 0.34 Marginal defects 6.7 4.5 0.52 Secondary caries 5.0 3.0 0.47 Narrative: At 12 months, ART showed slightly lower survival; however, differences were not statistically significant. ART maintained acceptable clinical longevity comparable to conventional restorations.

The present randomized clinical study evaluated the one-year clinical performance of atraumatic restorative treatment (ART) compared with conventional resin composite restorations in primary molars. The findings demonstrated that ART achieved an 88.3% success rate at 12 months, which was statistically comparable to the 92.5% success observed with conventional restorations. These results support the growing body of evidence that ART is a clinically acceptable minimally invasive alternative for managing carious lesions in primary teeth. The ART survival rate observed in this study closely aligns with the randomized clinical trial reported by Bonifácio et al., who documented an 86% survival of ART restorations in primary molars over a similar follow-up period [1]. Likewise, de Amorim et al. found no significant difference in one-year survival between ART and conventional restorations in primary molars, reinforcing that high-viscosity glass ionomer cement can withstand functional demands in primary dentition [3]. The consistency of these findings across independent trials confirms that ART offers reliable short-term restoration longevity. A major advantage of ART observed in the present study was significantly reduced chair-side treatment time. This finding mirrors observations by Innes et al., who reported that minimally invasive pediatric dentistry techniques, including ART, improve clinical efficiency and child cooperation by avoiding rotary instrumentation and anesthesia [4]. Shorter procedure time is particularly beneficial in young children with limited attention spans and in community dental programs with high patient turnover. Postoperative discomfort scores were lower in the ART group. This result corroborates the systematic analysis by Mickenautsch and Yengopal, who demonstrated that ART is associated with lower pain perception due to the absence of mechanical drilling and injection anesthesia [12]. Reduced discomfort improves child acceptance of dental care and may foster positive long-term dental attitudes. Secondary caries occurrence was low and not significantly different between the two groups. The fluoride-releasing property of glass ionomer cement used in ART likely contributed to caries inhibition at restoration margins. Schwendicke et al. demonstrated that ART restorations exert a preventive effect on adjacent enamel demineralization, especially in high-caries-risk children [6]. Additionally, Martinez-Mier et al. confirmed sustained fluoride release from modern glass ionomer materials, supporting their role in caries prevention [11]. This therapeutic advantage of ART is clinically valuable in populations where oral hygiene maintenance is suboptimal. Marginal integrity defects were slightly more frequent in ART restorations, although the difference was not statistically significant. This trend is consistent with laboratory and clinical evidence indicating that glass ionomer cements have lower wear resistance compared with resin composites [5]. Nevertheless, Frencken et al. concluded in their systematic review that marginal deterioration of ART restorations in primary teeth generally remains within clinically acceptable limits throughout the exfoliation timeline [7]. Therefore, the modest marginal changes observed in this study are unlikely to compromise overall treatment success. The comparable survival outcomes between ART and conventional restorations observed in the present study are further supported by the meta-analysis conducted by Schwendicke and Frencken, which reported no significant difference in restoration longevity between the two approaches in primary teeth [2]. These collective findings indicate that ART is not merely an interim solution but a definitive restorative option for appropriately selected lesions. The relevance of ART has further increased following the COVID-19 pandemic, during which aerosol-generating dental procedures were discouraged. Meng et al. highlighted ART as a safe, non-aerosol-generating alternative for pediatric dental care in infection-control-conscious environments [8]. The present study’s results provide additional clinical evidence supporting continued integration of ART into routine pediatric practice beyond pandemic-related restrictions. From a public health perspective, Raggio et al. demonstrated that ART programs implemented in community settings achieve restoration survival comparable to conventional clinic-based care while expanding access to underserved populations [14]. This aligns with the present study’s implication that ART can bridge treatment gaps in areas lacking advanced dental infrastructure. Limitations of this study include its single-center design and one-year follow-up period. Longer follow-up studies extending until natural exfoliation of treated primary molars are recommended. Additionally, operator blinding was not feasible due to procedural differences, although examiner blinding minimized assessment bias [15-20]. Overall, the present findings, supported by contemporary randomized trials and systematic reviews, confirm that ART provides a clinically effective, patient-friendly, and resource-efficient restorative strategy for primary teeth.

Atraumatic restorative treatment demonstrated clinical success comparable to conventional resin composite restorations in primary molars at one-year follow-up. ART offered significant advantages in reduced treatment time and lower postoperative discomfort, without compromising restoration survival or caries control. These findings support ART as a reliable minimally invasive alternative for pediatric restorative care, particularly in young or anxious children and in resource-limited settings. Wider adoption of ART can contribute to improved access to child dental services and enhanced preventive oral health strategies. Long-term studies extending to natural exfoliation of primary teeth are recommended to confirm sustained clinical performance.

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