Efficacy of silver modified atraumatic restorative treatment (SMART) versus atraumatic restorative treatment (ART) for caries control in primary teeth: a systematic review and meta-analysis.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261325936, PROSPERO CRD420261325936.