Outcomes of silver-modified atraumatic restorative technique (SMART) in carious primary teeth: a systematic review and meta-analysis of randomised clinical studies

Background: This systematic review evaluated the outcomes of Silver Modified Atraumatic Restorative Treatment (SMART) in managing carious primary teeth. Methods: Following the International Prospective Register of Systematic Reviews (PROSPERO) registration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search of ten databases identified randomised clinical studies published in English from January 2010 to May 2025. Study selection, data extraction, and quality assessment were independently conducted, with the risk of bias assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) tool and evidence levels determined via the Oxford Centre for Evidence-Based Medicine (OCEBM) tool. Data analysis included single- and two-arm meta-analyses, sensitivity analysis, subgroup analysis, meta-regression, and evaluation of publication bias. Results: Nine studies published between 2022 and 2025 were included, with eight used for meta-analysis. Most of the included primary studies originated from Egypt (n = 6) and India (n = 3). Weighted mean success rates for SMART were 94.9% (Confidence Interval (CI): (90.7, 99.1)), 82.0% (CI: (71.0, 93.0)), and 69.5% (CI: (52.4, 86.6)) at 3-, 6-, and 12-month follow-ups, respectively. Funnel plots indicated slight asymmetry at 3 and 12 months, while the 6-month plot appeared relatively symmetrical. A two-arm meta-analysis found SMART achieved success rates comparable to Atraumatic Restorative Treatment (ART) at 6- and 12-month follow-ups (p > 0.05), with no significant data heterogeneity. Subgroup analysis revealed higher success rates when marginal adaptation was used as the evaluation criterion compared to pain or mobility (p < 0.05). Meta-regression indicated that sample size did not affect heterogeneity, and Egger’s test showed no publication bias was detected. Conclusions: Findings suggested that SMART appears to be an effective alternative for treating carious primary teeth, but further research is needed to standardise evaluation criteria and confirm long-term efficacy. The PROSPERO Registration: ID: CRD42023480630.