The NHANES III survey indicated, that while over 90% of those 13 years old or older had experienced some minor loss of periodontal attachment, only 25% had attachment loss of 3 to 4 mm, and
only 15% had 5 mm or greater attachment loss.”

Attachment loss (both number of affected people and severity) increased with age. Gingival recession also increased with age.

While 86% of the older adults experienced some recession, only 40% of the overall population had recession.” More severe recession (3 mm or greater) affected half of older adults. Because of the increasing percentage of recession with age, there is a corresponding increased percentage of root caries.

Oral Cancer. Oral and pharyngeal cancer is the sixth most common neoplastic diseases An estimated 30,750 new cases of oropharyngeal cancer are expected to be diagnosed in the United States in 1999, which will be 3% of all cancers diagnosed .
The mortality rate associated with oral cancer has not improved in the last 40 years. Ultimately, 50% of people who have oral cancer die as a result of the malignancy, and 8440 deaths were predicted in the United States in 1999.

Teeth at Risk to Dental Disease. In 1989, Reinhardt and others used some survey results in combination with other studies and Bureau of Census population projections to determine and predict how many teeth would be at risk to dental disease. Their findings reported that in 1980 2.8 billion teeth were at risk to dental disease, with expectations of 4 billion in 1990, 4.4 billion by 2000, and 5 billion by 2030.

Thus between 1990 and 2030 there will be a projected increase of 1 billion teeth at risk to dental disease. This increase will occur because of a decreased rate of tooth loss combined with the aging of the baby boomers. Between 1990 and 2030, there will also be a projected 73% increase in people ages 45 and older and a 104% increase in senior adults, thereby resulting in 90% more teeth in the 45-and-older age group and 153% more teeth in the senior adult group.’

The future demand for operative dentistry care will increase. As previously noted, the population will increase, with the greatest increase occurring in the older adult component of society. Because these increased numbers of adults will retain more teeth, there will be more teeth at risk to dental disease, and many of these teeth will require operative care. In further exploring these expectations, several other factors must be addressed.

While in 1988 to 1991, more than 9 out of 10 adults (18 years and older) were dentate, only about 30% had all of their teeth .36 Those adults who had teeth averaged 23.5 teeth . 36 Both edentulism and the number of teeth present are strongly influenced by age. For example, the 1988 to 1991 National Health and Nutrition Examination Survey (NHANES) III revealed that 100% of the group ages 18 to 24 were dentate, while 44% of the group 75 years and older were edentulous. Likewise, the 18- to 24-year-old dentate group averaged 27.1 teeth, while the 75-years-and-older group had only 9 teeth.

However, the older age groups still showed the greatest decreases in edentulism and increases in retained teeth. In a 1971 to 1974 survey, 45.6% of people ages 65 to 74 were edentulous. In the NHANES 1111988 to 1991 survey only 28.6% of this age group was edentulous, and half of those were edentulous 20 years before the survey, indicating that only about 12% of that age group had actually become edentulous in the last 20 years.

Edentulism will continue to decrease, and more teeth will be retained. This will result in more teeth being at risk to dental disease, which may result in both increased need and demand for dental care.

Also, of the 2.5 DMFS for the years 1988 to 1991, almost 80% were filled surfaces, with the remaining 20% primarily being decayed surfaces. The affected DMFS surfaces were: (1) occlusal, 1.4; (2) facial or lingual, 0.8; and (3) mesial and distal, 0.3. 31 This indicates that occlusal surfaces were five times more likely to be involved than proximal surfaces. 12 This also indicates that sealant usage could be a significant method to further reduce caries in children.

Although the percentage of children with sealants almost doubled between the 1986 to 1987 and 1988 to 1991 surveys, only one of five children had sealants at the latter period.

The decayed, missing, or filled permanent teeth (DMFT) averaged 1.6 for the 1988 to 1991 survey. Of these teeth, 21% were decayed, 78% filled, and 1% missing.

When comparing the ds/dfs and DS/DMFS per person, the primary tooth ratio was twice that of the permanent tooth ratio, suggesting less treatment of primary teeth. 12
All of these figures and comparisons indicate a continuing decline in caries in the permanent dentition of children.

Still, caries continues to affect millions of U.S. adolescents and adults. Almost 94% of dentate adults showed evidence of coronal caries and almost 23% showed root caries in the 1988 to 1991 survey The total DMFS for all adults was about 50, while for dentate adults it was about 40; for the latter group almost 22 of the surfaces were decayed or filled, with most of those (19) being filled surfaces .

Also for dentate adults, the average number of root-surface carious lesions was 1, and half of those lesions were not filled. The prevalence of caries in adults increased markedly with age 21 (Table 1-2, as it relates to root caries only), and when all caries is considered, the aggregate caries increment may be higher in people over 55 years old than in children.

Over 100 million Americans have dental insurance, which in 1996 covered approximately 49% of all dental care costs. 16 Dental insurance grew steadily from 1975 to 1990, then leveled off. However, because of it, dental care has become less expensive for the typical consumer of dental services.

Total real dental expenditures increased from $25.8 billion in 1970 to $47.6 billion in 1996 .3 In the early 1970s, dental spending grew at about the same rate as other personal health care spending and faster than the overall economy. In 1978, the growth rate in the dental sector flattened, and since then dental spending has increased more slowly than either personal health spending or the overall economy.

In considering the future demand for operative dentistry, an assessment of the current and projected status of caries, missing teeth, and periodontal health is briefly presented here, followed by a projection of the increased numbers of teeth that will be at risk to dental disease in the future.

Caries. The incidence of caries has decreased. This reduction in caries is a result of increased usage of sealants and improved homecare efforts, but primarily it is a result of increased exposure to fluoride.

Fluoridation of community water systems began in Grand Rapids, Michigan, in 1945. However, only 62% of the U.S. population on public water supplies currently receives fluoridated water;” this represents approximately 145 million people. Fluoridation also protects 360 million people in approximately 60 countries worldwide.”

The expanded use of dietary fluoride supplements, school-based fluoride mouth-rinse programs, professional topical fluoride applications, and fluoride toothpastes also has contributed to this reduction.’ For example, over one fourth of the school districts in the United States offer schoolchildren the opportunity to participate in a fluoride mouth-rinse program.

General Health. The general health of the U.S. population is good. The ability to prevent or cure infectious disease has led to an increase in life expectancy, and the ability to control (partially or fully) some chronic diseases is resulting in a larger proportion of older adults in the population.

Life expectancy rates in 1991 were 80 years for men and 84 years for women , 9 compared to 1776 when the Declaration of Independence was signed and life expectancy was only 35 years . 53 In 1994, Americans spent $949 billion on health care . More recent projections indicate that the projected total U.S. health care expenditures of $1.1 trillion (13.5% of the GDP) in 1997 will increase to $2.2 trillion (16.2% of the GDP) by 2008.

However, access to and financial resources for health care are problems for some segments of society.

More than 30 million Americans do not have health insurance;4 and older adults (those over the age of 65) are responsible for four fifths of nursing home costs and one third of all health expenditures and physician fees Dental Health.

Americans generally have good dental health. Most understand the benefits of good dental health and practice good oral homecare. Except for some of current older adults, most Americans do not believe that the eventual loss of teeth is inevitable. Consequently, they are willing to invest their resources for dental health care. In 1994, $42.2 billion were spent on dental care in the United States this represented 4.4% of all health care costs for that year. Private patients paid about half of dental costs from their out-of-pocket funds. The government paid only $1.8 billion of dental costs, representing only 4.3% of dental spending for 1994. Thus the public share of dental costs was very low, while taxpayers paid 44% of the total health care costs for that year.

However, it is projected that dental spending will more than double between 1994 and 2008, reaching $93.1 billion by 2008.

Children ages 5 to 17 are experiencing less caries. In comparing the results of four U.S. surveys it can be noted that the number of caries-free children is increasing and the average number of decayed, missing, and filled tooth surfaces (DMFS [for permanent teeth] or dmfs [for primary teeth]) is decreasing. In the 1971 to 1974 survey, only 26% of the children were caries-free, but by 1988 to 1991, 54.7% were caries-free. Likewise, in 1971 to 1974, children averaged 7.1 DMFS; this decreased
to 2.5 in 1988 to 1991, a 65% reduction.

However, over 45% of the total group ages 5 to 17 did have caries in the latest survey, and the percentage of caries-free children increased with age within the group. Fewer adolescents (12 to 17 years) than children (5 to 11 years) were caries-free (33% to 74%). Thus by age 17, almost three out of every four adolescents have experienced caries. Also, of the 2.5 DMFS for the years 1988 to 1991, almost 80% were filled surfaces, with the remaining 20% primarily being decayed surfaces. The affected DMFS surfaces were: (1) occlusal, 1.4; (2) facial or lingual, 0.8; and (3) mesial and distal, 0.3.

This indicates that occlusal surfaces were five times more likely to be involved than proximal surfaces.This also indicates that sealant usage could be a significant method to further reduce caries in children. Although the percentage of children with sealants almost doubled between the 1986 to 1987 and 1988 to 1991 surveys, only one of five children had sealants at the latter period.

Over 100 million Americans have dental insurance, which in 1996 covered approximately 49% of all dental care costs. 16 Dental insurance grew steadily from 1975 to 1990, then leveled off. However, because of it, dental care has become less expensive for the typical consumer of dental services.

Total real dental expenditures increased from $25.8 billion in 1970 to $47.6 billion in 1996 .In the early 1970s, dental spending grew at about the same rate as other personal health care spending and faster than the overall economy. In 1978, the growth rate in the dental sector flattened, and since then dental spending has increased more slowly than either personal health spending or the overall economy.

In considering the future demand for operative dentistry, an assessment of the current and projected status of caries, missing teeth, and periodontal health is briefly presented here, followed by a projection of the increased numbers of teeth that will be at risk to dental disease in the future. Caries. The incidence of caries has decreased.

This reduction in caries is a result of increased usage of sealants and improved homecare efforts, but primarily it is a result of increased exposure to fluoride. Fluoridation of community water systems began in Grand Rapids, Michigan, in 1945. However, only 62% of the U.S. population on public water supplies currently receives fluoridated water;” this represents approximately 145 million people. Fluoridation also protects 360 million people in approximately 60 countries worldwide.”

The national deficit may not be eliminated, but it will become a lesser and lesser percentage of the Gross Domestic Product (GDP). Annual improvement of the GDP and productivity growth are projected to be at least equal to earlier periods in U.S. history that are considered “good” economic times.

If inflation and
unemployment continue at reasonable levels (in 1998,unemployment was only 4.3% and inflation was approximately 2%),16 there will be more discretionary income available, and discretionary income is generally what is utilized for dental health expenditures.

Thus it appears that the economic forecast for the United States is good. With more discretionary income and more health care benefits for the adult segment of society, the demand for future dental services should increase.

Corrosion-resistant amalgam alloys have been developed that will enhance the oral health of the population by providing longerlasting restorations.
All of the factors just mentioned have played an important role in the development of operative dentistry.

They have resulted in a reduction of the incidence of caries and a more conservativeand effective approach toward treatment, with the ultimate result of improved oral health for all populations.

Because of the dynamic status of operative dentistry, many future developments and advancements will undoubtedly occur. These advances in technology, science, and materials will have a significant effect on the future practice of and demand for operative dentistry. However, there are other factors that will also affect the future of operative dentistry.

To project the future demand for operative dentistry treatment, both current and projected dental health in the United States must be identified. This necessitates a projection of demographic changes, economic factors, and dental health and the effect of these on the future demand for dental services.

These past (and future) developments illustrate the dynamics of operative dentistry, a constantly changing and advancing discipline. The development of the high-speed handpiece played a dramatic role in the more conservative and efficient removal of tooth structure for restorative procedures. The use of high-speed instrumentation, along with the acknowledged benefits of water coolants, also led to the concept of four-handed dentistry.

Major changes in operatory equipment design followed, resulting in a more comfortable, efficient, and productive setting for the delivery of dental care.
The mechanical bonding of restorations to tooth structure by etching enamel and dentin and the use of bonding systems has led to the development of many new composite restorative materials, as well as conservative restorative bonding techniques. Studies on filler composition and polymerization methodology for composite materials have resulted in both increased esthetic qualities and resistance to wear. Similarly, the benefits of sealants are becoming more widely accepted for the prevention of pit-and-fissure caries.

Increased knowledge about the carious process and the beneficial effects of multiple fluoride application has resulted in a decrease in caries incidence. Likewise, the increasing professional emphasis on caries prevention is as important as the recent technologic and scientific advancements.

The recognition that most dental disease is preventable has resulted in better patient self-care and more conservative efforts by dentists in treatment. Increased research on biomaterials has led to the introduction of vastly improved dental materials. Developments in impression materials and gold foil and advancements in knowledge about liners and sealers are also factors that have resulted in better care and treatment for patients.

Advances in metallurgy have resulted in a variety of improved alloys that are either already available or are being developed. Corrosion-resistant amalgam alloys have been developed that will enhance the oral health of the population by providing longerlasting restorations.