With an increase in the populations of older adults retaining more teeth those who are frail and or functionally dependant frequently have poor oral health. Restoring root caries in these populations can be challenging so the use of atraumatic restorative treatment which was first developed to provide care in low income counties has been suggested as an alternative to conventional restorative treatment.
The aim of this review was to compare the efficacy of atraumatic restorative treatment (ART) and conventional treatment (CT) for the restoration of root caries lesions in older adults.
Methods
Searches were conducted in the Medline/PubMed, Embase and Cochrane CENTRAL databases with no restrictions on language or publication date. Randomised controlled trials (RCTs) comparing the survival of ART and CT restorations placed for treatment of root caries lesions in older adults were considered. The main outcome was restoration failure.
Two reviewers independently selected studies, extracted data and assessed risk of bias using the Cochrane tool. The certainty of the evidence was assessed using the GRADE approach. Meta-analysis was conducted for per-protocol (PP), intention-to-treat (ITT) and best-case scenarios. A trial sequential analysis was conducted to control for the risk of random errors.
Results
- 3 RCTs involving 130 patients (463 restorations) were included.
- The trial used glass ionomer cement (GIC), high viscosity GIC or resin-modified GIC.
- Marginal defect and retention loss were the main reasons for restoration failure.
- Risk of bias was considered high or moderate in all but one trial.
- ART was associated with a significantly increased risk of failure Odds Ratio (OR) = 2.06 (95%CI; 1.06 to 4.00) in PP- but not in ITT analysis OR=1.36 (95%CI; 0.92 to 2.02).
- Analyses for best-case scenarios found great uncertainty introduced by attrition.
- No firm evidence was reached according to the trial sequential analysis.
Conclusions
The authors concluded: –
For restoration of root caries, there is insufficient data to clearly rule out whether differences between ART and CT exist. Limited available data indicate there might be an increased risk of failure for ART.
Comments
3 major databases were searched for this review but only 3 trials involving a small number of patients could be included. Because of the type on intervention blinding of the operators or patients was not possible so these elements were not considered when assessing risk of bias. While the available evidence suggested a higher failure rate for ART the available evidence is limited in amount and quality. The GRADE assessment of the certainty of the evidence was reported as low but give the risk of bias assessment this seems generous. With the anticipated growth in the number of institutionalised older adults with potentially greater numbers of teeth at risk there is need for high quality studies to assess the effectiveness of treatments for root caries using broader parameters as suggested by the authors.
Links
Primary Paper
Göstemeyer G, da Mata C, McKenna G, Schwendicke F. Atraumatic vs conventional restorative treatment for root caries lesions in older patients: Meta- and trial sequential analysis. Gerodontology. 2019 May 24. doi: 10.1111/ger.12409. [Epub ahead of print] PubMed PMID:31125136.
Other references
Dental Elf – Atraumatic Restorative Treatment blogs
