SMART in Geriatric Dentistry: Rationale and Evidence Gaps for Root Caries Management

Population ageing has resulted in a growing number of older adults retaining natural dentition, with a consequent rise in the prevalence of root caries lesions (RCLs). These lesions are strongly associated with gingival recession, hyposalivation, multimorbidity, polypharmacy, and functional dependence, all of which can limit tolerance to conventional restorative care and compromise long-term restoration survival. Minimal intervention dentistry has, therefore, gained increasing relevance in geriatric practice. Silver diamine fluoride (SDF) and atraumatic restorative treatment (ART) are established minimally invasive approaches, while silver-modified atraumatic restorative treatment (SMART) integrates both strategies. However, its role in managing geriatric RCLs remains insufficiently defined.

This review critically examines the biological rationale, current evidence, clinical indications, limitations, and knowledge gaps associated with SMART for root caries management in older adults. Clinical evidence supports SDF as a non-restorative option for arresting active RCLs in older populations. Because SDF alone is less invasive than SMART, it should be preferred when lesion arrest is the principal treatment objective and the lesion remains cleansable, asymptomatic, and functionally acceptable. A restorative intervention may be indicated for selected cavitated lesions when loss of anatomical contour results in persistent plaque-retentive morphology, impaired cleansability or function, or structural rehabilitation needs. However, evidence evaluating SMART derives predominantly from paediatric and laboratory studies, and its comparative effectiveness over SDF alone, ART, or other restorative approaches has not been demonstrated in older adults. The combination of SDF and high-viscosity glass-ionomer cement (HVGIC) is therefore supported by mechanistic plausibility rather than geriatric clinical evidence. Important uncertainties remain regarding appropriate case selection, treatment sequencing, long-term restoration survival, subgingival performance, retreatment needs, cost-effectiveness, and patient-reported outcomes.