Is SMART as effective as ART for treating early childhood caries?

SMART (silver modified atraumatic restorative treatment) and ART (atraumatic restorative treatment) are both minimally invasive ways to treat early childhood caries, which is tooth decay in young children. ART involves cleaning out decayed tooth tissue and filling the cavity with a glass ionomer cement, a type of tooth-colored filling material. SMART adds silver diamine fluoride, a liquid that helps stop decay, before placing the filling. The short answer from the available evidence is that the two approaches appear to work about equally well for controlling decay in baby teeth ³⁸.

What the research says

A 2026 systematic review and meta-analysis pooled six randomized clinical trials with 398 children and found no statistically significant difference in overall clinical success between SMART and ART (odds ratio 1.28; 95% CI 0.91 to 1.80; p = 0.16) ³. The included trials had an overall low risk of bias, which strengthens confidence in this finding ³. A separate 2026 randomized split-mouth trial of 32 children aged 3 to 7 years, each receiving both treatments, reported 6-month success rates of 67.6% for ART and 70.5% for SMART, again with no significant difference (p = 0.66) ⁸. That trial also noted that SMART showed slightly better caries arrest, meaning it stopped decay from progressing a bit more often ⁸.

Both techniques fall under the umbrella of minimally invasive care. A 2023 systematic review of randomized trials found that ART, SMART sealants, silver diamine fluoride, nano-silver fluoride, and sodium fluoride varnish were all successful in halting early childhood caries progression and were well accepted by children and parents, even when children were uncooperative ⁶. That review also noted that the most common side effect of silver diamine fluoride is permanent black discoloration of treated tooth surfaces ⁶, which is relevant because SMART uses silver diamine fluoride ⁸.

It is worth putting this into context. Early childhood caries is very common: an umbrella review of studies in Africa found prevalence ranging from 17% to 57% of children ⁴. A broader conceptual review describes it as the result of disrupted development of the infant oral ecosystem, shaped by factors from pregnancy through the first 1,000 days of life, including maternal microbes, feeding practices, diet, and tooth eruption ². This means treatment choices sit within a larger picture of prevention and early-life factors, not just the filling technique itself.

One limitation: the meta-analysis is recent and based on a relatively small total number of children (398), so the evidence base, while promising, is not enormous ³. The split-mouth trial was also small, with 32 children ⁸. Larger and longer trials would help confirm these findings.

What to ask your doctor

• Ask whether SMART or ART is the better fit for your child's specific teeth and cavities, given that research shows similar success rates ³⁸.
• Ask about the risk of black discoloration from silver diamine fluoride, since SMART uses it and this is a known side effect ⁶.
• Ask how your child's diet, feeding habits, and oral hygiene at home might affect how well either treatment lasts ²⁴.
• Ask what follow-up schedule is recommended to check whether the treatment is working and whether new cavities appear ³⁸.
• Ask whether prevention options like fluoride varnish or sealants should be part of the plan alongside treatment ⁶.