uLllnl1lCn Anu PlS1C8?

DLIINI1ICN
Opetotlve Jeotlstty ls tbe ott ooJ scleoce of tbe Jloqoosls
tteotmeot ooJ ptoqoosls of Jefects of teetb tbot Jo oot tepolte
foll covetoqe testototloos fot cottectloo 5ocb tteotmeot
sboolJ tesolt lo tbe testototloo of ptopet tootb fotm fooctloo
ooJ estbetlcs wblle molotololoq tbe pbysloloqlc loteqtlty of
tbe teetb lo botmooloos telotloosblp wltb tbe oJjoceot botJ
ooJ soft tlssoes oll of wblcb sboolJ eobooce tbe qeoetol
beoltb ooJ welfote of tbe potleot
PlS1C8?
AlLhough opetotlve Jeotlstty wos ooce cooslJeteJ to be tbe
eotltety of tbe cllolcol ptoctlce of Jeotlstty Loday many of
Lhe areas prevlously lncluded under operaLlve denLlsLry
have become speclalLy areas As lnformaLlon lncreased
and Lhe need for oLher complex LreaLmenLs was recognlzed
areas such as endodonLlcs prosLhodonLlcs and
orLhodonLlcs became denLal speclalLles Powever operaLlve
denLlsLry ls sLlll recognlzed as Lhe foundaLlon of
denLlsLry and Lhe base from whlch mosL oLher aspecLs of
denLlsLry evolved
ln Lhe unlLed SLaLes denLlsLry orlglnaLed ln Lhe sevenLeenLh
cenLury when several barberdenLlsLs were
senL from Lngland 1he pracLlce of Lhese early denLlsLs
conslsLed malnly of LooLh exLracLlons because denLal
carles aL LhaL Llme was consldered a gangrenellke dlsease
Many pracLlced denLlsLry whlle pursulng oLher
llvellhoods and some Lraveled from one area Lo anoLher
Lo provlde Lhelr denLal servlces 1hese early denLlsLs
learned Lhelr Lrade by servlng apprenLlceshlps under
more experlenced pracLlLloners LaLer lL became known
LhaL LreaLmenL of Lhe defecLlve parL of a LooLh (Lhe cavlLy)
could occur by removal of Lhe cavlLy and replacemenL
of Lhe mlsslng LooLh sLrucLure by fllllng Lhe cavlLy
wlLh some Lype of maLerlal Much of Lhe knowledge
and many of Lhe Lechnlques for Lhe flrsL successful LooLh
resLoraLlons were developed ln Lhe unlLed SLaLes Powever
much of Lhe pracLlce of denLlsLry durlng Lhe foundlng
years of Lhls counLry was noL based on sclenLlflc
knowledge and dlspuLes ofLen arose regardlng LreaLmenL
Lechnlques and maLerlals Cne such dlspuLe concernlng
Lhe use of amalgam as a resLoraLlve maLerlal played a parL
ln Lhe esLabllshmenL of Lhe 8alLlmore College of uenLal
Surgery ln 184037 whlch marked Lhe offlclal blrLh of formal
denLal educaLlon as a dlsclpllne ln 1867 Parvard
unlverslLy esLabllshed Lhe flrsL unlverslLyafflllaLed denLal
program29
lL was ln Lhls same perlod ln lrance LhaL Louls asLeur
dlscovered Lhe role of mlcroorganlsms ln dlsease3 a
flndlng LhaL would have a slgnlflcanL effecL on Lhe developlng
denLal and medlcal professlons Also ln Lhe
unlLed SLaLes durlng Lhls Llme conLrlbuLlons by Cv
8lack8 became Lhe foundaLlon of Lhe denLal professlon
lock who had boLh honorary denLal and honorary
medlcal degrees teloteJ tbe cllolcol ptoctlce of Jeotlstty to
o scleotlflc bosls 1hls sclenLlflc foundaLlon for operaLlve
denLlsLry was furLher expanded by 8lacks son ArLhur
SLudles commlssloned by Lhe Carnegle loundaLlon Lhe
llexner reporL22 ln 1910 and Lhe Cles reporL22 ln 1926
furLher ldenLlfled Lhe need for esLabllshlng denLal and
medlcal educaLlonal sysLems on a flrm sclenLlflc foundaLlon
1he prlmary needs reporLed by Lhese sLudles
were relaLlng cllnlcal pracLlce Lo Lhe baslc sclences prescrlblng
admlsslons and currlculum crlLerla and promoLlng
unlverslLybased programs
1hus Lhe early days of lLlneranL and frequenLly uneducaLed
denLlsLs ended uenLlsLs began Lo be educaLed ln
Lhe baslc sclences as well as cllnlcal denLlsLry resulLlng
ln pracLlLloners who possessed and demonsLraLed lnLellecLual
and sclenLlflc curloslLy 1he herlLage of operaLlve
denLlsLry ls fllled wlLh such pracLlLloners ln addlLlon Lo
Lhe 8lacks oLhers such as Charles L Woodbury Lk
WedelsLaedL Waldon 1 lerrler and Ceorge Pollenback
made slgnlflcanL conLrlbuLlons Lo Lhe early developmenL
of operaLlve denLlsLry
AlLhough segmenLs of whaL consLlLuLed early operaLlve
denLlsLry have now branched lnLo denLal speclalLles
operaLlve denLlsLry conLlnues Lo be a ma[or parL of
mosL denLal pracLlces4 and Lhe demand for lL wlll
noL decrease ln Lhe foreseeable fuLure 48 Powever Lhe
number of resLoraLlve servlces provlded by uS denLlsLs
dld decllne from 233 mllllon ln 1979 Lo 202 mllllon ln
199042 Also Lhe percenLage of weekly Llme spenL on operaLlve
procedures decreased from 38 ln 1981 Lo 31
ln 1993 42 1hese changes have occurred because of
greaLer emphasls by denLlsLs Lo lncrease Lhe number of
prevenLlve and dlagnosLlc servlces and Lhls lncreased
focus on prevenLlon and dlagnosls ls represenLed ln Lhls
LexLbook
1he conLrlbuLlons of many pracLlLloners educaLors
and researchers LhroughouL Lhe world have resulLed ln
operaLlve denLlsLry belng recognlzed Loday as a sclenLlflcally
based dlsclpllne LhaL plays an lmporLanL role ln enhanclng
denLal healLh no longer ls operaLlve denLlsLry
consldered only Lhe LreaLmenL of cavlLles wlLh fllllngs
Modem operaLlve denLlsLry lncludes Lhe dlagnosls
and LreaLmenL of many problemsnoL [usL carles 8ecause
Lhe scope of operaLlve denLlsLry has exLended far
beyond Lhe LreaLmenL of carles Lhe Lerm cavlLy ls no
longer used ln Lhls LexLbook Lo descrlbe Lhe preparaLlon
of a LooLh Lo recelve a resLoraLlve maLerlal lnsLead mechanlcal
alLeraLlons Lo a LooLh as parL of a resLoraLlve procedure
wlll be referred Lo as Lhe LooLh preparaLlon
lAC1C8S AllLC1lnC
CL8A1lvL 18LA1MLn1
INDICA1ICNS
1he lndlcaLlons for operaLlve procedures are numerous
Powever Lhey can be caLegorlzed lnLo Lhree prlmary
LreaLmenL needs (1) carles (2) malformed dlscolored
nonesLheLlc or fracLured LeeLh and (3) resLoraLlon replacemenL
or repalr 1he speclflc procedures assoclaLed
wlLh Lhese LreaLmenL lndlcaLors are covered ln subsequenL
chapLers
CCnSluL8A1lCnS
8efore any operaLlve LreaLmenL a number of conslderaLlons
are lnvolved lncludlng (1) an undersLandlng of
and appreclaLlon for lnfecLlon conLrol Lo safeguard boLh
healLh servlce personnel and paLlenLs (see ChapLer 8) (2) a
Lhorough examlnaLlon of noL only Lhe affecLed LooLh buL
also Lhe oral and sysLemlc healLh of Lhe paLlenL (3) a dlagnosls
of Lhe denLal problem LhaL recognlzes Lhe lnLeracLlon
of Lhe affecLed area wlLh oLher body Llssues (4) a
LreaLmenL plan LhaL has Lhe poLenLlal Lo reLurn Lhe affecLed
area Lo a sLaLe of healLh and funcLlon Lhereby enhanclng
Lhe overall healLh and wellbelng of Lhe paLlenL
(3) an undersLandlng of Lhe maLerlal Lo be used Lo resLore
Lhe affecLed area Lo a sLaLe of healLh and funcLlon lncludlng
a reallzaLlon of boLh Lhe maLerlals llmlLaLlons and
Lechnlques lnvolved ln uslng lL (6) an undersLandlng of
Lhe oral envlronmenL lnLo whlch Lhe resLoraLlon wlll be
placed (7) Lhe blologlc knowledge necessary Lo make Lhe
prevlously menLloned deLermlnaLlons (8) an undersLandlng
of Lhe blologlc basls and funcLlon of Lhe varlous
LooLh componenLs and supporLlng Llssues (9) an appreclaLlon
for and knowledge of correcL denLal anaLomy and
(10) Lhe effecL of Lhe operaLlve procedure on oLher denLal
LreaLmenLs SubsequenL chapLers ampllfy Lhese facLors ln
relaLlon Lo speclflc operaLlve procedures
ln summary Lhe placemenL of a resLoraLlon ln a LooLh
requlres Lhe denLlsL Lo pracLlce applled human blology
and mlcroblology use prlnclples of mechanlcal englneerlng
possess hlghly developed Lechnlcal skllls and
demonsLraLe arLlsLlc ablllLles
CCnSL8vA1lvL A8CACP
AlLhough LooLh preparaLlons for operaLlve procedures
orlglnally adhered Lo Lhe concepL of exLenslon for prevenLlon
lncreased knowledge of prevenLlon meLhods
advanced cllnlcal Lechnlques and lmproved resLoraLlve
maLerlals have now provlded a more conservaLlve approach
Lo Lhe resLoraLlon of LeeLh 1hls newer approach
ls a resulL of Lhe reducLlon ln carles lncldence because of
lncreased knowledge abouL carles lncreased prevenLlve
emphasls use of mulLlple fluorlde appllcaLlons and
proper sealanL appllcaLlon
Cngolng research efforLs ln operaLlve denLlsLry have
provlded oLher beneflLs lor example hlghcopper amalgam
resLoraLlons demonsLraLe slgnlflcanL lmprovemenLs
ln early sLrengLh corroslon reslsLance marglnal lnLegrlLy
and longevlLy Lhan LradlLlonal amalgams ln addlLlon
Lhe bondlng of maLerlals Lo LooLh sLrucLure has made
posslble dramaLlc lmprovemenLs ln composlLe ceramlc
and glass lonomer resLoraLlons and Lhe developmenL of
expanded resLoraLlve appllcaLlons of Lhese maLerlals
More conservaLlve approaches are now avallable for
(1) many Lyplcal resLoraLlve procedures (Classes l ll lll
lv and v) (2) dlasLema closure procedure (3) esLheLlc
and/or funcLlonal correcLlon of malformed dlscolored
or fracLured LeeLh and (4) acLual replacemenL of LeeLh
When compared wlLh pasL LreaLmenL modallLles Lhese
newer approaches resulL ln slgnlflcanLly less removal of
LooLh sLrucLure
AlLhough Lhese are only examples Lhey demonsLraLe
Lhe currenL emphasls on conservaLlon of LooLh sLrucLure
@be ptlmoty tesolts of coosetvotlve tteotmeot ote teteotloo of
mote lotoct tootb sttoctote ooJ less ttoomo to tbe polp tlssoe
ooJ cootlqooos soft tlssoe noL only wlll Lhe remalnlng
LooLh sLrucLure be sLronger buL Lhe resLoraLlon should
be more easlly reLalned offer greaLer esLheLlc poLenLlal
and cause less alLeraLlon ln lnLeaarch and lnLerarch
relaLlonshlps
LfforLs for Lhe conservaLlve resLoraLlon of LeeLh are ongolng
8esearch acLlvlLy ls conLlnulng Loward Lhe developmenL
of maLerlals and Lechnlques Lo compleLely bond
resLoraLlve maLerlals Lo LooLh sLrucLure Lhe ob[ecLlves
belng Lo (1) slgnlflcanLly reduce Lhe necesslLy for exLenslve
LooLh preparaLlons (2) sLrengLhen Lhe remalnlng
LooLh sLrucLure and (3) provlde beneflLs such as less mlcroleakage
less recurrenL carles and lncreased reLenLlon
of Lhe maLerlal wlLhln Lhe LooLh 1hese efforLs wlll ulLlmaLely
beneflL Lhe oral healLh of Lhe publlc
u?nAMlCS Cl CL8A1lvL uLn1lS18?
ln Lhe fuLure advances ln LreaLmenL Lechnlques
phllosophles and maLerlals almosL cerLalnly wlll be
made [usL as ln Lhe pasL several decades Lechnologlcal
and sclenLlflc advances have dramaLlcally affecLed Lhe
need for demand for and dellvery of resLoraLlve servlces
1hese pasL (and fuLure) developmenLs lllusLraLe
Lhe dynamlcs of operaLlve denLlsLry a consLanLly changlng
and advanclng dlsclpllne
1he developmenL of Lhe blqbspeeJ booJplece played a
dramaLlc role ln Lhe more conservaLlve and efflclenL removal
of LooLh sLrucLure for resLoraLlve procedures 1he
use of hlghspeed lnsLrumenLaLlon along wlLh Lhe acknowledged
beneflLs of waLer coolanLs also led Lo Lhe
concepL of footbooJeJ Jeotlstty Ma[or changes ln operaLory
equlpmenL deslgn followed resulLlng ln a more
comforLable efflclenL and producLlve seLLlng for Lhe dellvery
of denLal care
1he mechanlcal bondlng of resLoraLlons Lo LooLh
sLrucLure by eLchlng enamel and denLln and Lhe use of
bondlng sysLems has led Lo Lhe developmenL of many
new composlLe resLoraLlve maLerlals as well as coosetvotlve
testototlve booJloq tecbolpoes SLudles on flller composlLlon
and polymerlzaLlon meLhodology for composlte
motetlols have resulLed ln boLh lncreased esLheLlc quallLles
and reslsLance Lo wear Slmllarly Lhe beneflLs of
seoloots are becomlng more wldely accepLed for Lhe prevenLlon
of plLandflssure carles
lncreased knowledge abouL Lhe carlous process and
Lhe beneflclal effecLs of mulLlple fluorlde appllcaLlon has
resulLed ln a decrease ln carles lncldence Llkewlse Lhe
lncreaslng professlonal empbosls oo cotles pteveotloo ls as
lmporLanL as Lhe recenL Lechnologlc and sclenLlflc advancemenLs
1he recognlLlon LhaL most Jeotol Jlseose ls
pteveotoble has resulLed ln beLLer paLlenL selfcare and
more conservaLlve efforLs by denLlsLs ln LreaLmenL
lncreased research on blomaLerlals has led Lo Lhe lnLroducLlon
of vostly lmptoveJ Jeotol motetlols uevelopmenLs
ln lmpresslon maLerlals and gold foll and advancemenLs
ln knowledge abouL llners and sealers are
also facLors LhaL have resulLed ln beLLer care and LreaLmenL
for paLlenLs Advances ln meLallurgy have resulLed
ln a varleLy of lmproved alloys LhaL are elLher already
avallable or are belng developed CorroslonreslsLanL
amalgam alloys have been developed LhaL wlll enhance
Lhe oral healLh of Lhe populaLlon by provldlng longerlasLlng
resLoraLlons
All of tbe foctots jost meotlooeJ bove ployeJ oo lmpottoot
tole lo tbe Jevelopmeot of opetotlve Jeotlstty @bey bove tesolteJ
lo o teJoctloo of tbe loclJeoce of cotles ooJ o mote coosetvotlve
ooJ effectlve opptoocb towotJ tteotmeot wltb tbe
oltlmote tesolt of lmptoveJ otol beoltb fot oll popolotloos
IAC1CkS AIILC1ING 1nL IU1UkL
DLMAND ICk CLkA1IVL
DLN1IS1k
8ecause of Lhe dynamlc sLaLus of operaLlve denLlsLry
many fuLure developmenLs and advancemenLs wlll undoubLedly
occur 1hese advances ln Lechnology sclence
and maLerlals wlll have a slgnlflcanL effecL on Lhe fuLure
pracLlce of and demand for operaLlve denLlsLry Powever
Lhere are oLher facLors LhaL wlll also affecL Lhe fuLure
of operaLlve denLlsLry
1o pro[ecL Lhe fuLure demand for operaLlve denLlsLry
LreaLmenL boLh currenL and pro[ecLed denLal healLh ln
Lhe unlLed SLaLes musL be ldenLlfled 1hls necesslLaLes a
pro[ecLlon of demographlc changes economlc facLors
and denLal healLh and Lhe effecL of Lhese on Lhe fuLure
demand for denLal servlces
DLMCGkAnICS
8eLween 1990 and 2030 Lhe uS populaLlon ls pro[ecLed
Lo lncrease by 146 mllllon people (Lo a LoLal of 394 mllllon)
4 1 and Lhe composlLlon of Lhe Amerlcan populaLlon
aL LhaL Llme wlll also be dlfferenL almosL one half (47)
of Lhe populaLlon wlll conslsL of mlnorlLles 41 and Lhe
numbers of older adulLs wlll be slgnlflcanLly hlgher
1hese populaLlon changes wlll affecL Lhe enLlre professlonal
llves of mosL of Lodays denLal school graduaLes
ln CcLober 1999 Lhe worlds populaLlon reached 6 bllllon
whlch represenLed a 1 bllllon lncrease durlng Lhe
prevlous 12 years uurlng Lhe LwenLleLh cenLury Lhe
world populaLlon Lrlpled and by 2100 Lhe world populaLlon
ls expecLed Lo reach 12 bllllon Whlle Lhe world
blrLh raLe ln 1999 was 370000 blrLhs each day 32 more
Lhan 30000 Amerlcans also reached Lhe age of 30 durlng
LhaL year 37
1he percenLage of olJet oJolts lo tbe popolotloo wlll locteose
subsLanLlally ln Lhe fuLure 1hls lncrease wlll occur
prlmarlly as a resulL of Lhe aglng of Lhe bobyboomet qeoetotloo
(Lhe flrsL of whom Lurned 30 years old on !anuary
1 1996) and Lhe lncreased llfe expecLancy for uS resldenLs
z 3 8y 2010 Lhose 63 years old and older wlll represenL
20 of Lhe populaLlons LhaL age group only
amounLed Lo 4 of Lhe populaLlon ln 1900 and 7 ln
1940 34 1hose 63 years old and older (senlor adulLs)
make up Lhe fasLesL growlng segmenL of socleLy growlng
Lwlce as fasL as Lhe general populaLlon lor example
lL ls pro[ecLed LhaL Lhe group of people 83 years old and
older wlll lncrease by 400 beLween 2000 and 2030 6
8ecause of lncreased llfe expecLancy Lhe babyboomer
generaLlon wlll grow older Lhan Lhe prevlous older adulL
segmenL of Lhe populaLlon Many of Lhe baby boomers
were noL exposed Lo fluorldaLed waLer durlng Lhelr formaLlve
years and consequenLly have had exLenslve
resLoraLlve denLal care Powever Lhls large segmenL of
Lhe populaLlon as well as oLher age cohorLs (excepL currenL
older adulLs) has developed an appreclaLlon for
denLal healLh and pracLlces reasonable denLal selfcare
Slnce mosL of Lhese lndlvlduals wlll reLaln more of Lhelr
LeeLh as Lhey age tbey wlll cteote o cootlooloq JemooJ fot
Jeotol setvlces because Lhey wlll noL only wanL Lo keep
Lhelr LeeLh buL also wlll experlence a sLandard of llvlng
LhaL wlll permlL a degree of dlscreLlonary lncome for
healLh care expendlLures
8ecause of Lhe aglng of Lhe uS populaLlon emphasls
wlll shlfL from Lhe needs of Lhe young Lo Lhe concerns
and demands of mlddleaged people and older adulLs
AlLhough Lhe absoluLe numbers of chlldren wlll noL decrease
subsLanLlally ln Lhe fuLure Lhelr percenLage ln Lhe
populaLlon and relaLlve lmporLance ln healLh care pollcles
wlll decrease Cn Lhe oLher hand older adulLs wlll
lncrease ln boLh absoluLe number and lmporLance Already
older adulLs (Lhose 63 years old and older) are recelvlng
a much hlgher percenLage of healLh care beneflLs
Lhan ls Lhelr percenLage of socleLy Such beneflLs wlll lncrease
as Lhe pollLlcal and economlc clouL of older adulLs
lncreases
LCCNCMIC IAC1CkS
no one can accuraLely pro[ecL Lhe economlc fuLure
Whlle Lhe uS economy wlll be parL of a more global
economy Lhe economlc pro[ecLlons for Lhe unlLed SLaLes
appear brlghL 1he naLlonal deflclL may noL be ellmlnaLed
buL lL wlll become a lesser and lesser percenLage
of Lhe Cross uomesLlc roducL (Cu) Annual lmprovemenL
of Lhe Cu and producLlvlLy growLh are pro[ecLed
Lo be aL leasL equal Lo earller perlods ln uS hlsLory LhaL
are consldered good economlc Llmes lf lnflaLlon and
unemploymenL conLlnue aL reasonable levels (ln 1998
unemploymenL was only 43 and lnflaLlon was approxlmaLely
2)16 Lhere wlll be more dlscreLlonary lncome
avallable and dlscreLlonary lncome ls generally
whaL ls uLlllzed for denLal healLh expendlLures
1hus lL appears LhaL Lhe economlc forecasL for Lhe
unlLed SLaLes ls good WlLh more dlscreLlonary lncome
and more healLh care beneflLs for Lhe adulL segmenL of
socleLy tbe JemooJ fot fotote Jeotol setvlces sboolJ
locteose
GLNLkAL AND DLN1AL nLAL1n
CI 1nL US CULA1ICN
ln conslderlng Lhe currenL and pro[ecLed denLal healLh of
Lhe uS populaLlon a brlef assessmenL of Lhe general
healLh of Lhe populaLlon ls necessary
Genera| nea|th 1he general healLh of Lhe uS populaLlon
ls good 1he ablllLy Lo prevenL or cure lnfecLlous
dlsease has led Lo an lncrease ln llfe expecLancy and Lhe
ablllLy Lo conLrol (parLlally or fully) some chronlc dlseases
ls resulLlng ln a larger proporLlon of older adulLs
ln Lhe populaLlon Llfe expecLancy raLes ln 1991 were 80
years for men and 84 years for women 9 compared Lo
1776 when Lhe ueclaraLlon of lndependence was slgned
and llfe expecLancy was only 33 years 33
ln 1994 Amerlcans spenL $949 bllllon on healLh care 43
More recenL pro[ecLlons lndlcaLe LhaL Lhe pro[ecLed LoLal
uS healLh care expendlLures of $11 Lrllllon (133 of
Lhe Cu) ln 1997 wlll lncrease Lo $22 Lrllllon (162 of
Lhe Cu) by 2008 44 Powever access Lo and flnanclal resources
for healLh care are problems for some segmenLs
of socleLy More Lhan 30 mllllon Amerlcans do noL have
healLh lnsurance4 and older adulLs (Lhose over Lhe age
of 63) are responslble for four flfLhs of nurslng home
cosLs and one Lhlrd of all healLh expendlLures and physlclan
fees 38
Denta| nea|th Amerlcans generally have good denLal
healLh MosL undersLand Lhe beneflLs of good denLal
healLh and pracLlce good oral homecare LxcepL for
some of currenL older adulLs mosL Amerlcans do noL belleve
LhaL Lhe evenLual loss of LeeLh ls lnevlLable ConsequenLly
Lhey are wllllng Lo lnvesL Lhelr resources for
denLal healLh care ln 1994 $422 bllllon were spenL on
denLal care ln Lhe unlLed SLaLes 43 Lhls represenLed 44
of all healLh care cosLs for LhaL year rlvaLe paLlenLs pald
abouL half of denLal cosLs from Lhelr ouLofpockeL
funds 1he governmenL pald only $18 bllllon of denLal
cosLs represenLlng only 43 of denLal spendlng for
1994 1hus Lhe publlc share of denLal cosLs was very low
whlle Laxpayers pald 44 of Lhe LoLal healLh care cosLs
for LhaL year43 Powever lL ls pro[ecLed LhaL denLal
spendlng wlll more Lhan double beLween 1994 and 2008
reachlng $931 bllllon by 2008 1he raLe of denLal spendlng
growLh wlll be approxlmaLely double LhaL of pro[ecLed
economlc growLh durlng Lhe same perlod 44
Cver 100 mllllon Amerlcans have denLal lnsurance
whlch ln 1996 covered approxlmaLely 49 of all denLal
care cosLs 16 uenLal lnsurance grew sLeadlly from 1973 Lo
1990 Lhen leveled off Powever because of lL denLal
care has become less expenslve for Lhe Lyplcal consumer
of denLal servlces
1oLal real denLal expendlLures lncreased from $238
bllllon ln 1970 Lo $476 bllllon ln 1996 3 ln Lhe early 1970s
denLal spendlng grew aL abouL Lhe same raLe as oLher
personal healLh care spendlng and fasLer Lhan Lhe overall
economy ln 1978 Lhe growLh raLe ln Lhe denLal secLor
flaLLened and slnce Lhen denLal spendlng has lncreased
more slowly Lhan elLher personal healLh
spendlng or Lhe overall economy 16
ln conslderlng Lhe fuLure demand for operaLlve denLlsLry
an assessmenL of Lhe currenL and pro[ecLed sLaLus
of carles mlsslng LeeLh and perlodonLal healLh ls brlefly
presenLed here followed by a pro[ecLlon of Lhe lncreased
numbers of LeeLh LhaL wlll be aL rlsk Lo denLal
dlsease ln Lhe fuLure
Carles 1he lncldence of carles has decreased 1hls reducLlon
ln carles ls a resulL of lncreased usage of
sealanLs and lmproved homecare efforLs buL prlmarlly
lL ls a resulL of lncreased exposure Lo fluorlde lluorldaLlon
of communlLy waLer sysLems began ln Crand
8aplds Mlchlgan ln 1943 Powever only 62 of Lhe
uS populaLlon on publlc waLer supplles currenLly recelves
fluorldaLed waLer Lhls represenLs approxlmaLely
143 mllllon people lluorldaLlon also proLecLs
360 mllllon people ln approxlmaLely 60 counLrles worldwlde
1he expanded use of dleLary fluorlde supplemenLs
schoolbased fluorlde mouLhrlnse programs
professlonal Loplcal fluorlde appllcaLlons and fluorlde
LooLhpasLes also has conLrlbuLed Lo Lhls reducLlon lor
example over one fourLh of Lhe school dlsLrlcLs ln Lhe
unlLed SLaLes offer schoolchlldren Lhe opporLunlLy Lo
parLlclpaLe ln a fluorlde mouLhrlnse program 3
Chlldren ages 3 Lo 17 are experlenclng less carles ln
comparlng Lhe resulLs of four uS surveys 1 (1able 11)
lL can be noLed LhaL Lhe number of carlesfree chlldren ls
lncreaslng and Lhe average number of decayed mlsslng
and fllled LooLh surfaces (uMlS for permanenL LeeLh or
dmfs for prlmary LeeLh) ls decreaslng ln Lhe 1971 Lo
1974 survey only 26 of Lhe chlldren were carlesfree
buL by 1988 Lo 1991 347 were carlesfree Llkewlse ln
1971 Lo 1974 chlldren averaged 71 uMlS Lhls decreased
Lo 23 ln 1988 Lo 1991 a 63 reducLlon
Powever over 43 of Lhe LoLal group ages 3 Lo 17 dld
have carles ln Lhe laLesL survey and Lhe percenLage of
carlesfree chlldren lncreased wlLh age wlLhln Lhe
group lewer adolescenLs (12 Lo 17 years) Lhan chlldren
(3 Lo 11 years) were carlesfree (33 Lo 74) 1hus by
age 17 almosL Lhree ouL of every four adolescenLs have
experlenced carles
Also of Lhe 23 uMlS for Lhe years 1988 Lo 1991 almosL
80 were fllled surfaces wlLh Lhe remalnlng 20
prlmarlly belng decayed surfaces 1he affecLed uMlS
surfaces were (1) occlusal 14 (2) faclal or llngual 08
and (3) meslal and dlsLal 03 31 1hls lndlcaLes LhaL occlusal
surfaces were flve Llmes more llkely Lo be lnvolved
Lhan proxlmal surfaces 12 1hls also lndlcaLes LhaL
sealanL usage could be a slgnlflcanL meLhod Lo furLher
reduce carles ln chlldren AlLhough Lhe percenLage of
chlldren wlLh sealanLs almosL doubled beLween Lhe 1986
Lo 1987 and 1988 Lo 1991 surveys only one of flve chlldren
had sealanLs aL Lhe laLLer perlod 12
1he decayed mlsslng or fllled permanenL LeeLh
(uMl1) averaged 16 for Lhe 1988 Lo 1991 survey Cf Lhese
LeeLh 21 were decayed 78 fllled and 1 mlsslng
When comparlng Lhe ds/dfs and uS/uMlS per person
Lhe prlmary LooLh raLlo was Lwlce LhaL of Lhe permanenL
LooLh raLlo suggesLlng less LreaLmenL of prlmary LeeLh 12
All of Lhese flgures and comparlsons lndlcaLe a conLlnulng
decllne ln carles ln Lhe permanenL denLlLlon of chlldren
SLlll carles conLlnues Lo affecL mllllons of uS adolescenLs
and adulLs AlmosL 94 of denLaLe adulLs showed
evldence of coronal carles and almosL 23 showed rooL
carles ln Lhe 1988 Lo 1991 survey 1he LoLal uMlS for all
adulLs was abouL 30 whlle for denLaLe adulLs lL was
abouL 40 for Lhe laLLer group almosL 22 of Lhe surfaces
were decayed or fllled wlLh mosL of Lhose (19) belng
fllled surfaces 43 Also for denLaLe adulLs Lhe average
number of rooLsurface carlous leslons was 1 and half of
Lhose leslons were noL fllled 1he prevalence of carles
ln adulLs lncreased markedly wlLh age 21 (1able 12 as lL
relaLes Lo rooL carles only) and when all carles ls consldered
Lhe aggregaLe carles lncremenL may be hlgher
ln people over 33 years old Lhan ln chlldren 2646
,lssloq @eetb uurlng Lhe pasL several decades
Lhere has been a sLeady reducLlon ln boLh edenLullsm
and numbers of LeeLh losL per person Whlle Lhese
Lrends lndlcaLe LhaL edenLullsm may be dlsappearlng
pottlol eJeotollsm wlll cootlooe Whlle ln 1988 Lo 1991
more Lhan 9 ouL of 10 adulLs (18 years and older) were
denLaLe only abouL 30 had all of Lhelr LeeLh 36 1hose
adulLs who had LeeLh averaged 233 LeeLh 36 8oLh edenLullsm
and Lhe number of LeeLh presenL are sLrongly lnfluenced
by age lor example Lhe 1988 Lo 1991 naLlonal
PealLh and nuLrlLlon LxamlnaLlon Survey (nPAnLS)
lll revealed LhaL 100 of Lhe group ages 18 Lo 24 were
denLaLe whlle 44 of Lhe group 73 years and older were
edenLulous Llkewlse Lhe 18 Lo 24yearold denLaLe
group averaged 271 LeeLh whlle Lhe 73yearsandolder
group had only 9 LeeLh Powever Lhe older age groups
sLlll showed Lhe greaLesL decreases ln edenLullsm and
lncreases ln reLalned LeeLh ln a 1971 Lo 1974 survey
436 of people ages 63 Lo 74 were edenLulous ln Lhe
nPAnLS 1111988 Lo 1991 survey only 286 of Lhls age
group was edenLulous and half of Lhose were edenLulous
20 years before Lhe survey lndlcaLlng LhaL only
abouL 12 of LhaL age group had acLually become edenLulous
ln Lhe lasL 20 years 21
LdenLullsm wlll conLlnue Lo decrease and more LeeLh
wlll be reLalned 1hls wlll resulL ln more LeeLh belng aL
rlsk Lo denLal dlsease whlch may resulL ln boLh lncreased
need and demand for denLal care
9etloJootol 5totos 1he nPAnLS lll survey lndlcaLed
LhaL whlle over 90 of Lhose 13 years old or older
had experlenced some mlnor loss of perlodonLal aLLachmenL
only 23 had aLLachmenL loss of 3 Lo 4 mm and
only 13 had 3 mm or greaLer aLLachmenL loss ALLachmenL
loss (boLh number of affecLed people and severlLy)
lncreased wlLh age Clnglval recesslon also lncreased
wlLh age Whlle 86 of Lhe older adulLs experlenced
some recesslon only 40 of Lhe overall populaLlon had
recesslon More severe recesslon (3 mm or greaLer) affecLed
half of older adulLs (1able 13) 8ecause of Lhe lncreaslng
percenLage of recesslon wlLh age Lhere ls a correspondlng
lncreased percenLage of rooL carles
Otol coocet Cral and pharyngeal cancer ls Lhe slxLh
mosL common neoplasLlc dlseases An esLlmaLed 30730
new cases of oropharyngeal cancer are expecLed Lo be
dlagnosed ln Lhe unlLed SLaLes ln 1999 whlch wlll be 3
of all cancers dlagnosed 33 1he morLallLy raLe assoclaLed
wlLh oral cancer has noL lmproved ln Lhe lasL 40 years
ulLlmaLely 30 of people who have oral cancer dle as a
resulL of Lhe mallgnancy and 8440 deaLhs were predlcLed
ln Lhe unlLed SLaLes ln 1999 33
@eetb ot klsk to ueotol ulseose ln 1989 8elnhardL
and oLhers used some survey resulLs ln comblnaLlon
wlLh oLher sLudles and 8ureau of Census populaLlon
pro[ecLlons Lo deLermlne and predlcL how many LeeLh
would be aL rlsk Lo denLal dlsease 1helr flndlngs reporLed
LhaL ln 1980 28 bllllon LeeLh were aL rlsk Lo denLal
dlsease wlLh expecLaLlons of 4 bllllon ln 1990 44 bllllon
by 2000 and 3 bllllon by 2030 48 1hus beLween 1990
and 2030 Lhere wlll be a pro[ecLed lncrease of 1 bllllon
LeeLh aL rlsk Lo denLal dlsease 1hls lncrease wlll occur
because of a decreased raLe of LooLh loss comblned wlLh
Lhe aglng of Lhe baby boomers 8eLween 1990 and 2030
Lhere wlll also be a pro[ecLed 73 lncrease ln people
ages 43 and older and a 104 lncrease ln senlor adulLs
Lhereby resulLlng ln 90 more LeeLh ln Lhe 43andolder
age group and 133 more LeeLh ln Lhe senlor adulL group
@be fotote JemooJ fot opetotlve Jeotlstty cote wlll locteose
As prevlously noLed Lhe populaLlon wlll lncrease
wlLh Lhe greaLesL lncrease occurrlng ln Lhe older adulL
componenL of socleLy 8ecause Lhese lncreased numbers
of adulLs wlll reLaln more LeeLh Lhere wlll be more LeeLh
aL rlsk Lo denLal dlsease and many of Lhese LeeLh wlll requlre
operaLlve care ln furLher explorlng Lhese expecLaLlons
several oLher facLors musL be addressed
DLN1AL MANCWLk
ln 1996 Lhere were 166423 professlonally acLlve denLlsLs
ln Lhe unlLed SLaLes 1en years earller Lhere were approxlmaLely
123000 denLlsLs 8eLween 1994 and 2020
Lhe number of professlonally acLlve denLlsLs ls expecLed
Lo lncrease by almosL 13 whlch wlll be less Lhan Lhe
expecLed populaLlon lncrease 1he number of denLlsLs
per 1000 people ls expecLed Lo decrease sllghLly beLween
1999 and 2020 14 ln 1990 Lhere were 038 denLlsLs per 1000
people Powever Lo keep LhaL raLlo Lhere would need
Lo be a 38 lncrease ln Lhe number of denLlsLs by 2030
because of Lhe lncreaslng mlnorlLy percenLage of Lhe
populaLlon lL ls LhoughL LhaL Lhe greaLesL lncrease
should be ln Lhe number of mlnorlLy denLlsLs 41 1hls lncreased
number of mlnorlLy denLlsLs ls noL llkely Lo occur
even Lhough beLween 1986 and 1996 Lhe proporLlon
of female denLal sLudenLs lncreased from 27 Lo 37
and Lhe proporLlon of whlLe male denLal sLudenLs decreased
from 84 Lo 7014
Whlle Lhe number of flrsLyear denLal school sLudenLs
decreased by 28 beLween 1976 (3936) and 1996
(4233)4 lL ls expecLed Lo lncrease by 36 beLween 1996
and 2020 (3773) 14 Llkewlse Lhe number of denLal
school graduaLes decreased by 29 beLween 1976 (3336)
and 1996 (3810) buL ls expecLed Lo lncrease by 42 from
1996 Lo 2020 (3414) Slnce 1986 slx uS denLal schools
have closed and one new one has opened 14
Cf acLlve prlvaLe denLal pracLlLloners 82 are general
denLlsLs and 92 own Lhelr denLal pracLlce 1he number
of hours worked per week decreased from 423 ln
1986 Lo 371 ln 1993 3 yeL Lhe hours per week spenL LreaLlng
paLlenLs lncreased durlng Lhe same perlodfrom
77 Lo 90and more of Lhls lncreased LreaLmenL Llme
was devoLed Lo dlagnosLlc and prevenLlve servlces
Lven Lhough Lhe enrollmenL ln denLal schools ls pro[
ecLed Lo lncrease Lhe pro[ecLed lncrease ln denLlsLs for
Lhe nexL several decades wlll noL be large 1herefore
Lhere wlll be fewer denLlsLs LreaLlng more people who
wlll have reLalned more LeeLh 1hls represenLs an effecLlve
lncrease ln Lhe demand for denLal care
kCILC1LD NLLD ICk CLkA1IVL DLN1IS1k
1he lncreased oombet of boots oeeJeJ fot opetotlve cote lo
tbe fotote wlll be for Lhe followlng operaLlve procedures
(1) resLoraLlons for LeeLh wlLh new carlous leslons (2)
resLoraLlons for LeeLh wlLh rooL carles (3) resLoraLlons Lo
replace exlsLlng faulLy resLoraLlons and (4) resLoraLlons
Lo enhance Lhe esLheLlc appearance of paLlenLs
New Car|es new carles wlll conLlnue Lo occur Lven
Lhough almosL 33 of chlldren (ages 3 Lo 17) are carlesfree
Lhe remalnlng 43 have carles 8y age 17 Lhree ouL
of four adolescenLs have experlenced carles AJolts especlolly
olJet oJolts bove blqb cotles totes As prevlously
menLloned when all carles ls consldered Lhe aggregaLe
carles lncremenL may be hlgher ln people over 33 years
old Lhan ln chlldren Less Lhan 6 of people ages 18
Lo 64 have no carles 17
koot Car|es 8ooL carles wlll lncrease due Lo Lhe lncreased
number of older adulLs who wlll reLaln more
LeeLh and experlence more glnglval recesslon AddlLlonally
many older adulLs may have sysLemlc problems
LhaL may dlrecLly or lndlrecLly alLer normal sallvary
funcLlonlng Lhus lncreaslng Lhe poLenLlal for rooL carles
formaLlon Whlle only one fourLh of all denLaLe adulLs
have evldence of rooL carles Lhe prevalence lncreases
markedly wlLh age (see 1able 12)
kep|acement kestorat|ons 8eplacemenL resLoraLlons
wlll also sLlmulaLe much fuLure demand 1here ls
a large need for replacemenL denLlsLry lL has been esLlmaLed
LhaL 73 of all operaLlve LreaLmenL ls due Lo replacemenL
of exlsLlng resLoraLlons 32 lurLhermore 70
of all resLoraLlons per year are replacemenLs of exlsLlng
resLoraLlons 1he knowledge LhaL baby boomers are
reachlng Lhelr older adulL years where hlgh numbers of
decayed and fllled LooLh surfaces ofLen occur documenLs
Lhe conLlnulng need for fuLure resLoraLlve care
More Lhan 30 of Lhe lncome from resLoraLlve procedures
ls from Lhe replacemenL of resLoraLlons ln paLlenLs
older Lhan 4038
Lsthet|c kestorat|ons 1he publlc has come Lo appreclaLe
Lhe posslblllLles of esLheLlc enhancemenLs from
denLal LreaLmenL due Lo publlclLy abouL bondlng publlclLy
ln Lhe form of magazlne arLlcles Lelevlslon shows
and speclal news programs ln 1990 lL was esLlmaLed
LhaL 10 of a denLlsLs gross lncome was derlved from
esLheLlc LreaLmenL on noncarlous LeeLh 47 More recenLly
lL has been reporLed LhaL one of every flve lnLracoronal
resLoraLlons done ln Lhe unlLed SLaLes are LooLhcolored
1hls same reporL sLaLes lL ls llkely LhaL Lhe more esLheLlcally
pleaslng maLerlals evenLually wlll be Lhe predomlnanL
lnLracoronal and exLracoronal resLoraLlve concepLs
18 WlLh more LeeLh belng reLalned more people
are llkely Lo seek appearance enhancemenLs especlally
when mosL such LreaLmenLs are relaLlvely slmple nonlnvaslve
and nonsLressful
U8LICS LkCL1ICN CI DLN1IS1k
1he publlcs percepLlon of denLlsLry ls anoLher facLor
LhaL wlll lnfluence wheLher Lhe lncreased numbers of
LeeLh and lncreased need for operaLlve servlces wlll be
converLed Lo lncreased demand lorLunaLely Lhe publlc
conslders denLlsLs and denLlsLry very poslLlvely 1he
publlc ranks a denLlsL as one of Lhe mosL respecLed
members of Lhe communlLy and denLlsLry has Lhe hlghesL
saLlsfacLlon raLlng when Lhe publlc assesses Lhe servlces
Lhey recelve LasLly Lhe publlc noL only Lhlnks
hlghly of Lhe denLal professlon Lhey also appreclaLe Lhe
beneflLs of good denLal healLh All of Lhls suggesLs a conLlnulng
demand for operaLlve servlces
A1ILN1 VISI1S
8ecause of the pro[ected s|gn|f|cant |ncrease |n the number
of senlor adulLs lL ls lmporLanL Lo conslder Lhelr pasL
use of denLal servlces as well as Lhelr poLenLlal economlc
sLaLus ln 1970 238 of senlor adulLs vlslLed a denLlsL
annually Lhls percenLage lncreased Lo 386 by 1983 24
Whlle before 1983 Lhls group averaged only 13 vlslLs Lo
Lhe denLlsL per year Lhey lncreased Lhelr denLal vlslLs
by 29 beLween 1983 and 1986318 Several years laLer
Lhey were reporLed Lo make more vlslLs Lo a denLlsL Lhan
any oLher age group
1he economlc sLaLus of adulLs wlll affecL Lhelr fuLure
denLal demand WlLh denLal expendlLures consldered
dlscreLlonary Lhe avallablllLy of dlscreLlonary lncome
wlll lnfluence Lhe amounL of denLal care soughL Cne
sLudy showed LhaL over one half of older adulLs wlLh annual
lncomes below $10000 had noL seen a denLlsL for 3
years whlle only 18 of Lhose wlLh lncomes over
$33000 had noL seen a denLlsL durlng Lhe same Llme perlod
38 Cverall older adulLs (over age 63) currenLly have
77 of Lhe flnanclal asseLs ln Lhe unlLed SLaLes 68 of
all money markeL funds and 80 of all money ln savlngs
and loans lnsLlLuLlons AddlLlonally 73 own Lhelr
own home wlLh 84 of Lhe morLgages already pald
off3 @betefote oew olJet oJolts ooJ fotote olJet oJolts wlll
oot ooly possess posltlve petceptloos oboot Jeotlstty ooJ Jeotol
beoltb bot olso wlll bove tbe ecooomlc meoos to secote tbe
Jeotol cote tbey oeeJ
lor all people ln Lhe unlLed SLaLes less Lhan 10 reporLed
havlng unmeL denLal care wanLs4 1hls reporL
furLher lndlcaLed LhaL Lhese lndlvlduals were more llkely
Lo (1) be ln Lhe pooresL healLh (2) have chronlc condlLlons
(3) be a head of household wlLh mlnlmal educaLlon
(4) have less famlly lncome or (3) have no denLal lnsurance
Powever almosL half of Lhls group lndlcaLed
LhaL Lhey had noL Lrled Lo obLaln denLal care even Lhough
almosL half also lndlcaLed LhaL Lhelr denLal problems llmlLed
Lhelr acLlvlLles 1he predomlnanL barrler Lo recelpL of
wanLed denLal care was a flnanclal conslderaLlon
1hese facLors affecLlng Lhe demand for operaLlve denLlsLry
pro[ecL an locteose lo opetotlve tteotmeot lo tbe fotote
1he lncreased number of older adulLs Lhe lncreased
number of LeeLh Lhe lncreased affluence of Lhe
populaLlon Lhe poslLlve lmage of denLlsLry and Lhe pro[ecLed
lncreased hours of operaLlve need all supporL Lhls
lncreased demand
IU1UkL CI CLkA1IVL
DLN1IS1k
Many slgnlflcanL advancemenLs ln healLh care occurred
ln Lhe LwenLleLh cenLury lncluded ln Lhese advancemenLs
are geneLlc alLeraLlons geneLlc englneerlng publlc
educaLlon vacclnes fluorldaLlon xrays compuLed
Lomography (C1) scans magneLlc resonance lmaglng
(M8l) anLlbloLlcs ulLrasound procedures and sanlLaLlon
uurlng Lhls cenLury llfe span doubled and Lhe
quallLy of llfe was greaLly lmproved Many of Lhese facLors
had an effecL on lmprovlng denLal care
8esearch ls Lhe prlmary caLalysL Lo professlonal
growLh and has greaLly added Lo Lhe undersLandlng of
Lhe eLlology dlagnosls and LreaLmenL of denLal dlseases
LxclLlng research ls occurrlng LhaL wlll have an
addlLlonal effecL on Lhe fuLure of operaLlve denLlsLry and
knowledge abouL new developmenLs and Lechnologles
wlll also affecL Lhe pracLlce 1hese developmenLs mlghL
be ln Lhe areas of molecular and cellular blology geneLlcs
pharmacology radlaLlon blology radlaLlon physlcs
and Lechnology Lomography dlglLal radlography quanLlLaLlve
llghLlnduced fluorescence elecLrlcal conducLlvlLy
ulLrasonography denLal maLerlals based on polymer
chemlsLry and lon exchange mlcroblology lmmunology
and behavloral sclence ln Lerms of fuLure sclenLlflc
achlevemenL lL ls noL dlfflculL Lo predlcL sLarLllng new
advances due Lo Lhe appllcaLlon of recomblnanL unA
Lechnology Lhe appllcaLlon of space age Lechnology and
Lhe general advancemenL of sclenLlflc meLhodology Advances
ln Lhese areas can have dlrecL lmpacL on denLal
pracLlce Lhrough Lhe developmenL of new LreaLmenLs
and prevenLlve modes new blomaLerlals appllcable Lo
denLal pracLlce and more sophlsLlcaLed Lechnlques Lo
measure Lhe healLh sLaLus of lndlvlduals 9
8esearch ln operaLlve denLlsLry ls now occurrlng ln a
number of flelds 1he use of lasers ln denLlsLry may lead
Lo a new mechanlsm for weldlng denLal alloys or alLerlng
LooLh sLrucLure ln LooLh preparaLlon Already lasers
are used ln eLchlng enamel and maklng enamel more reslsLanL
Lo demlnerallzaLlon LxLended uses of bondlng
Lechnlques and furLher developmenLs ln composlLe and
adheslve resLoraLlve maLerlals wlll lead Lo even more
conservaLlve resLoraLlve Lechnlques 1he beneflclal use
of composlLes ln posLerlor LeeLh has become evldenL
Much research and cllnlcal LesLlng also ls belng done on
casLable or pressed ceramlc maLerlals 1he lnLroducLlon
of compuLergeneraLed resLoraLlons has sLlmulaLed
much lnLeresL and furLher reflnemenL of such Lechnology
ls occurrlng mptovemeots lo composltes oJbeslve systems
costoble cetomlcs ooJ compotetqeoetoteJ testototloos
coolJ tesolt lo o slqolflcoot Jecteose lo tbe ose of metol olloy
systems lo opetotlve Jeotlstty Also lncreaslng concern
abouL Lhe poLenLlal LoxlclLy of some componenLs of currenL
alloy sysLems such as mercury and nlckel may resulL
ln decreased use of Lhese sysLems ln Lhe fuLure SlgnlflcanL
eovltoomeotol coocetos are surfaclng regardlng
Lhe dlsposal of cerLaln maLerlals used ln denLlsLry especlally
mercury
LfforLs are also belng made Lo develop an anLlcarles
vacclne Powever even lf developed Lhe wldespread
use of such an agenL may noL occur ln Lhe foreseeable fuLure
ln Lhe unlLed SLaLes because of Lhe already documenLed
carles reducLlon from mulLlple fluorlde use llmlLaLlons
lmposed by regulaLory agencles and concern
abouL posslble slde effecLs Whereas Lhe use of such an
agenL ln developlng counLrles may provlde greaLer lmmedlaLe
beneflLs lLs use ln Lhe unlLed SLaLes may be
conflned Lo hlghrlsk paLlenLs
MeLhods for adheslvely bondlng composlLe maLerlals
Lo denLln have lmproved 1hese developmenLs have had
dramaLlc effecLs on Lhe pracLlce of operaLlve denLlsLry
resulLlng ln mlnlmal LooLh preparaLlon 1he capaclLy Lo
develop relaLlvely predlcLable and endurlng adheslon
beLween resLoraLlve maLerlals and LooLh sLrucLure has
had Lhe greaLesL lmpacL on resLoraLlve denLlsLry ln recenL
decades 30 ffectlve Jeotlo booJloq slgnlflcanLly lncreases
LooLh conservaLlon31 whlle poLenLlally reduclng
paLlenL anxleLy 1echnlques used for such bondlng procedures
may also lncrease producLlvlLy
llnally Lhe Jeveloploq coocepts lo cotloloqy may have
ma[or lmpllcaLlons ln deallng wlLh denLal carles 1he lncreased
knowledge abouL facLors lnvolved ln Lhe carlous
process has placed a greaLer emphasls on LreaLlng Lhe
carlous leslon by means oLher Lhan resLoraLlve Lechnlques
lL seems posslble Lo foresee a Llme when dlagnosls
and LreaLmenL Lechnlques are so reflned as Lo preclude
Lhe necesslLy of LooLh preparaLlon Lo conLrol some
carlous acLlvlLy 1he remlnerallzaLlon of a LooLh surface
affecLed by a beglnnlng carlous leslon wlll noL only decrease
Lhe need for resLoraLlve care buL also resulL ln a
LooLh surface LhaL wlll be more reslsLanL Lo subsequenL
carlous aLLacks 1he developmenL of approprlaLe fluorlde
and anLlmlcroblal appllcaLlons and Lechnlques Lo
produce Lhls remlnerallzaLlon ls now a reallLy All of
Lhese developmenLs and changes wlll occur ln a fuLure
envlronmenL of lncreased need for operaLlve LreaLmenL
because of more people especlally adulLs who wlll reLaln
more of Lhelr LeeLh @be empbosls of tbe ptofessloo wlll
sblft to cote fot tbe seolot oJolt seqmeot of tbe popolotloo
1hls populaLlon wlll requlre slgnlflcanL denLal care due
noL only Lo replacemenL needs for exlsLlng resLoraLlons
buL also Lo developmenL of new carles especlally rooL
carles lncreased undersLandlng of LreaLmenL meLhods
for older adulLs wlll be requlred as wlll lmproved
knowledge perLalnlng Lo Lhelr overall medlcal healLh
uenLal research efforLs wlll conLlnue seeklng LreaLmenL
meLhods LhaL wlll be more efflclenL and less sLressful for
Lhese paLlenLs and bonded resLoraLlons boLh amalgam
and composlLe wlll provlde beneflLs ln LreaLlng Lhls segmenL
of Lhe populaLlon
SUMMAk
Many facLors have been presenLed ln Lhls chapLer some
of whlch wlll be expanded ln oLher chapLers of Lhls
book @be objectlve bos beeo to lJeotlfy tbe foctots tbot lofloeoce
opetotlve Jeotlstty botb toJoy ooJ lo tbe fotote CerLalnly
changes ln Lodays socleLy changes ln Lhe fuLure
oral healLh of Lhe uS populaLlon and developmenLs
wlLhln Lhe dlsclpllne of operaLlve denLlsLry wlll affecL
fuLure pracLlce
Many exclLlng advances have already been made and
oLhers are expecLed lmporLanL progress ls belng made
Loward Lhe Llme when carles and perlodonLal dlsease
wlll no longer be ma[or publlc healLh problems As
parL of Lhelr professlonal responslblllLles denLlsLs have
an obllgaLlon Lo monlLor Lhe denLal welfare of Lhe publlc
and ad[usL Lhelr paLLerns of LreaLmenL accordlngly
rofesslonal eLhlcs dlcLaLe LhaL denLlsLs musL embrace
new and accepLed denLal LreaLmenL maLerlals and devlces
and aL Lhe same Llme dlscard ouLmoded LreaLmenL
and Lechnlques ln pursulL of opLlmal oral healLh
for Lhe publlc
uenLal educaLlon should sLrlve Lo produce pracLlLloners
who can Lhlnk crlLlcally uslng Lhe sclenLlflc meLhod
so Lhey can be ln a poslLlon Lo evaluaLe fuLure clalms relaLed
Lo advanclng Lhe professlon uenLlsLry musL also
conLlnue Lo broaden lLs knowledge of Lhe blologlc basls
on whlch lL ls founded racLlLloners musL conLlnually
famlllarlze Lhemselves wlLh Lhe advances belng made
lncreased research acLlvlLy and conLlnued pracLlLloner
adapLablllLy wlll resulL ln lmproved oral healLh of populaLlons
LhroughouL Lhe world
1he fuLure of operaLlve denLlsLry ls good! 1hls chapLer
has presenLed some of Lhe reasons 1he remalnder of