SMART and ART show comparable success for early childhood caries, meta-analysis findsSilver and standard treatments show similar success for children's teeth

Frontiers in Medicine Published August 20, 2026 Study authors: Katia Noemi Rubio-Membrillo, María Victoria Espinoza-Salcedo, Heber Isac Arbildo-Vega, Omar Edmundo … DOI ↗ Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

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Key Takeaway

Consider both SMART and ART as viable options for caries control in primary teeth, but interpret results with caution due to low certainty.

This meta-analysis evaluated the clinical effectiveness of silver modified atraumatic restorative treatment (SMART) versus atraumatic restorative treatment (ART) for managing early childhood caries in primary teeth. The analysis included 398 unique pediatric participants, with a minimum follow-up of 6 months. The primary outcome was overall clinical success.

The pooled analysis found no statistically significant difference between SMART and ART for overall clinical success (OR = 1.28, 95% CI: 0.91–1.80, p = 0.16). The authors conclude that both SMART and ART are viable and effective strategies for caries control in primary teeth. However, they emphasize that the certainty of the available evidence is low, and a Trial Sequential Analysis (TSA) demonstrated that the cumulative evidence remains inconclusive.

Limitations of the meta-analysis include the low certainty of the evidence and the inconclusive cumulative evidence as indicated by TSA. The authors note that further large-scale randomized controlled trials are required to establish definitive clinical guidelines. Adverse events, serious adverse events, and discontinuations were not reported in the included studies.

For clinicians, this meta-analysis suggests that SMART and ART may be comparable options for treating early childhood caries, but the low certainty and inconclusive evidence mean that treatment decisions should be individualized. The findings support the use of either technique, but clinicians should be aware that the evidence base is not yet robust enough to recommend one over the other definitively.

How this fits prior evidence

This meta-analysis extends prior coverage on early childhood caries (ECC) by comparing two restorative techniques. Prior coverage highlighted the high and variable prevalence of ECC in African children (17%-57%) and associations between oral microbiota and caries risk. This meta-analysis adds comparative effectiveness data for SMART versus ART, showing no significant difference in clinical success, but with low certainty and inconclusive evidence. It does not directly address prevalence or microbiota associations, but it reinforces the need for effective caries management in primary teeth, consistent with the high burden noted earlier.

When a child gets a cavity in their first set of teeth, parents and doctors need to know which treatments actually work. One common method is called atraumatic restorative treatment (ART). Another version, known as SMART, adds silver to the mix. Some people wonder if that extra step makes a difference for the child's dental health.

A review of data from 398 children showed no significant difference in success between these two methods. Both options were found to be effective ways to manage and treat cavities in primary teeth over at least six months. The results suggest that both techniques are reliable choices for pediatric care.

While the findings are encouraging, it is important to note that the evidence currently has low certainty. Because the data is still somewhat limited, researchers say more large-scale trials are needed to set firm clinical guidelines. For now, both methods stand as viable options for treating children's teeth.

What this means for you:

Both silver and standard restorative treatments show similar success rates for treating cavities in children's primary teeth.

Common questions

Is the silver treatment better than the standard one?

The study found no statistically significant difference between the silver-based treatment (SMART) and the standard restorative treatment (ART). Both methods were shown to be effective for managing cavities in children's primary teeth over a minimum of six months.

Is it safe to use these treatments on children?

The study found that both SMART and ART are viable strategies for controlling tooth decay in children. However, the researchers noted that the current evidence has low certainty, so you should speak with a dentist about which option is best for your child.

How long do these treatments last?

The study looked at clinical success over a minimum of six months. While both methods were effective during this time, more large-scale trials are needed to establish definitive guidelines for long-term care.

Study Details

Study typeMeta analysis

EvidenceLevel 1

PublishedAug 2026

View Original Abstract ↓

Early childhood caries represents a severe global public health problem. Faced with this, Atraumatic Restorative Treatment (ART) and Silver Modified Atraumatic Restorative Treatment (SMART) have positioned themselves as minimally invasive approaches. The objective of this study was to evaluate and compare the clinical efficacy of SMART versus conventional ART for caries control in primary teeth. A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines, searching for randomized clinical trials (RCTs) across seven databases up to March 2026. Studies with a minimum follow-up period of 6 months were included. The risk of bias was assessed using the RoB 2 tool, and the certainty of evidence was evaluated using the GRADE approach. Seven reports derived from six randomized clinical trials with an overall low risk of bias were included in the qualitative synthesis, representing 398 unique pediatric participants. One trial generated two complementary publications reporting different outcomes; therefore, only the publication reporting clinical success contributed to the quantitative synthesis. A total of six randomized clinical trials were included in the meta-analysis, which showed no statistically significant differences in overall clinical success between SMART and ART (OR = 1.28; 95% CI: 0.91–1.80; p = 0.16). Furthermore, Trial Sequential Analysis (TSA) demonstrated that the cumulative evidence remains inconclusive. There is no statistically significant difference in overall clinical success between SMART and ART for the primary dentition. Both are viable and effective strategies; however, the certainty of the available evidence is low, and therefore future large-scale RCTs are required to establish definitive clinical guidelines. https://www.crd.york.ac.uk/PROSPERO/view/CRD420261325936, PROSPERO CRD420261325936.

SMART and ART show comparable success for early childhood caries, meta-analysis findsSilver and standard treatments show similar success for children's teeth

How this fits prior evidence

Common questions

Study Details

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SMART and ART show comparable success for early childhood caries, meta-analysis findsSilver and standard treatments show similar success for children's teeth

How this fits prior evidence

Common questions

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