Effectiveness of ART and Conventional Treatment - Practice-based Clinical Trial

Study Overview
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Brief Summary
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Background: Dental caries is still a public health problem among Brazilian children and doubts still exist regarding the most effective restorative technique. The aim of this pragmatic randomized clinical trial is to evaluate the effectiveness of single and multiple-surfaces restorations performed following the Atraumatic Restorative Treatment (ART) premises compared with Conventional Treatment (CT) in primary and permanent teeth. Methods: A total of 1,214 5-to-13 years-old children with at least one single or multiple-surface dentin caries lesion in primary or permanent molars will be selected in the public schools of Barueri-SP. The participants will be randomly divided into 2 groups: CT (Filtek Bulk Fill - 3M) and ART (Ketac Molar Easy Mix - 3M) and treated by ten untrained dentists in a dental office inside the schools. The restorations will be evaluated after 6, 12 and 24 months by an independent trained and calibrated examiner. The restoration and tooth survival, the cost-effectiveness analysis between the two groups and the operator preference of the treatment regarding the techniques will be also evaluated. Kaplan-Meier survival analysis and log-rank test will be applied to the survival of restorations. All the average event rates in the two groups will be modelled and compared with a Cox proportional hazard shared frailty model since there is an operator cluster-effect. The significance level for all analyses will be 5%.

Detailed Description
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Background: Dental caries is still a public health problem among Brazilian children and doubts still exist regarding the most effective restorative technique. The aim of this pragmatic randomized clinical trial is to evaluate the effectiveness of single and multiple-surfaces restorations performed following the Atraumatic Restorative Treatment (ART) premises compared with Conventional Treatment (CT) in primary and permanent teeth. Methods: A total of 1,214 5-to-13 years-old children with at least one single or multiple-surface dentin caries lesion in primary or permanent molars will be selected in the public schools of Barueri-SP. The participants will be randomly divided into 2 groups: CT (Filtek Bulk Fill - 3M) and ART (Ketac Molar Easy Mix - 3M) and treated by ten untrained dentists in a dental office inside the schools. The restorations will be evaluated after 6, 12 and 24 months by an independent trained and calibrated examiner. The restoration and tooth survival, the cost-effectiveness analysis between the two groups and the operator preference of the treatment regarding the techniques will be also evaluated. Kaplan-Meier survival analysis and log-rank test will be applied to the survival of restorations. All the average event rates in the two groups will be modelled and compared with a Cox proportional hazard shared frailty model since there is an operator cluster-effect. The significance level for all analyses will be 5%. Discussion: Our hypothesis is that despite similar expected effectiveness between ART using high viscosity GIC and conventional treatment using composite resin when treating single or multiple-surface in posterior primary and permanent teeth, ART presents superior cost-effectiveness. The results of this trial will support decision-making by clinicians and policy makers Keywords: atraumatic restorative treatment, composite resin, glass ionomer cement, randomized clinical trial, cost effectiveness analysis

Official Title
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Effectiveness of Atraumatic Restorative Treatment and Conventional Restorations in Primary and Permanent Dentition: A Practice-based Clinical Trial

Conditions
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Dental Caries

Intervention / Treatment
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* Procedure: Atraumatic Restorative Treatment - Ketac Molar Easy Mix
* Procedure: Conventional Restoration - Composite Resin (Bulk Fill)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Children aging between 6 and 14 years presenting good health conditions spontaneous demand for treatment by parents or legal guardians whose parents or legal guardians accept and sign the consent form with at least one occlusal or occlusal proximal caries lesion in primary or permanent molars only occlusal and/or occlusal-proximal surfaces with caries lesions with dentin involvement Exclusion Criteria: severe behavioral issues presence of fistula or abscess near the selected tooth presence of pulp exposure in the selected tooth presence of mobility in the selected tooth

Ages Eligible for Study
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Minimum Age: 6 Years
Maximum Age: 14 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Conventional Restoration<br>Conventional Restoration - Composite Resin (Bulk Fill) | Procedure: Conventional Restoration - Composite Resin (Bulk Fill)<br>* Occlusal and occlusal-proximal composite resin restorations in primary and permanent molars using the Scotchbond Multi-purpose adhesive system and the Filtek Bulk Fill composite resin wil be performed. Local anesthesia can be used if necessary. Access to caries lesion will be done using a round bur. Infected carious tissue will be removed with hand instruments. The cavity will be etched for 15 seconds followed by rising and drying for the same amount of time. The cavity will be restored with composite resin. Occlusion will be checked.<br>|
| Experimental: Atraumatic Restorative Treatment<br>Atraumatic Restorative Treatment - Ketac Molar Easy Mix | Procedure: Atraumatic Restorative Treatment - Ketac Molar Easy Mix<br>* Occlusal and occlusal-proximal ART restorations in primary and permanent molars using the high viscosity GIC Ketac Molar Easy mix will be performed. No local anesthesia will be used. Infected carious tissue will be removed with hand instruments, and the cavities restored with GIC (Glass Ionomer Cement). The cavity will be filled with GIC. After the press-finger technique, the excess of material will be removed and occlusion will be checked.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The restoration survival | The treatments will be classified as successful when they present a clinical satisfactory aspect. Otherwise, minor failures will be analyzed. Minor failures are those in which there is a defect in the restoration/crown, but it does not interfere with the tooth health. | Every 6 months up to 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Longevity of the tooth | For evaluation of this outcome will be considered successful the restoration even a minor failure of the restoration (scores 00 to 30). Only the restored teeth that presents symptoms of pulp inflammation or need for extraction (scores 40 and 50) will be considered as failure, since it cannot be considered as a successful treatment for the tooth. The main objective of a restoration is to aprovide patient a condition for improved hygiene, can enable inactivation of injury, plus the return of the masticatory function of that tooth, so the scores considered minor failures is not considered failure for the tooth (Bonifácio et al., 2012). | Every 6 months up to 18 months | 
| Cost-effectiveness assessment | Treatment costs will be calculated considering professional costs and procedure costs. In order to calculate the professional cost the time spent in each session will be converted in hours and multiplied by the medium income of the dentist per hour as related by the Brazilian Ministry of Labour and Employment ($36,23). On the other hand, to estimate the procedure cost, it will be considered both variable cost, which includes electricity and equipment depreciation, and materials cost. To calculate the equipment depreciation (peripherals, dental chair and instrumental), we will consider their price, the lifespan of five years and a monthly use of 160 hours, using an estimate value per hour of $1,81. All materials used in each procedure will have their specifications and quantity registered. Prices will be inferences from the market value converted in US Dollars and obtained by the medium of the values from different places that commercialized the referred products. | Through study completion, an average of 18 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Dental Atraumatic Restorative Treatment, Composite Resins, Primary Teeth, Permanent Teeth, Clinical Effectiveness, Cost Analysis