How these trends might affect the diversity of dental practices in the United States is also discussed.

	AGE AND DIVERSITY

TOP ABSTRACT AGE AND DIVERSITY THINK COHORTS TRENDS IN DISEASE PATTERNS DIVERSITY AMONG DENTAL PRACTICES ACCOUNTABILITY REFERENCES

 
Most practicing dentists over 50 years of age have witnessed a significant age shift among their patients. A generation ago, many adult patients thought that they would lose their teeth as they got older. For most older adults, full dentures used to be the norm when they became edentulous.¹ All of that has changed for the better.

Most older adults today have retained some or most of their natural dentition. In fact, 46.3 percent of adults 70 years of age or older have an average of 20.5 teeth.² The majority of the baby boomers (the first fluoride generation) will enter their retirement years beginning in 2011 with nearly a full complement of teeth.³ Thus, treating older patients with fixed prosthodontics who have retained some or the majority of their natural teeth will be a common experience in most dental practices in the 21st-century (Figures 1 and 2). In addition, the diversity of the American population is projected to increase in the 21st century. Attitudes toward oral health and wellness vary among cultures.

View larger version (100K): [in this window] [in a new window]   Figure 1. This 71-year-old patient desired esthetic dentistry as part of her comprehensive dental care. The patient, who retained all of her natural dentition and has 12-year bonded restorations, wanted porcelain veneers to improve esthetics and eliminate "black spaces" between the teeth.

View larger version (95K): [in this window] [in a new window]   Figure 2. Patient from Figure 1 after placement of porcelain veneers from second biscuspid to second biscuspid on both arches, and a ceramometal crown on the mandibular left central incisor.

	THINK COHORTS

TOP ABSTRACT AGE AND DIVERSITY THINK COHORTS TRENDS IN DISEASE PATTERNS DIVERSITY AMONG DENTAL PRACTICES ACCOUNTABILITY REFERENCES

 
Insight into understanding patient expectations is provided by thinking of patients as members of the generation or age cohort in which they grew up.⁴ The so-called "dental IQ" seems in large part to be determined by early life experience with dentistry and oral health. For example, parents in 1915 taught their children to expect to lose all of their teeth by age 40. Forty was considered to be old age, and pregnant women were told that they would probably lose a tooth with the birth of each child.

Meanwhile, parents in 1945 taught their children that they could keep their natural teeth if they went to the dentist to have their cavities filled. Indeed, these cohorts who are currently middle-aged have retained their teeth by taking advantage of modern dentistry, which offered restorations, endodontic and periodontal therapy, and new prosthodontic treatments. This extensive dental work will require ongoing maintenance as this cohort ages and faces the effects of chronic diseases in the future.

Parents in 1985, however, taught their children that they did not have to have tooth decay. It became widely known that fluorides in one form or another and sealants could prevent dental caries. Thus, each generation, or age cohort, has higher expectations for oral health than preceding generations.

	TRENDS IN DISEASE PATTERNS

TOP ABSTRACT AGE AND DIVERSITY THINK COHORTS TRENDS IN DISEASE PATTERNS DIVERSITY AMONG DENTAL PRACTICES ACCOUNTABILITY REFERENCES

 
With the fundamental change in the retention of teeth, the patterns of dental and oral diseases are also changing. When this was first realized in the early 1980s,⁵ many observers thought that the decline in childhood dental caries would result in less need for dental treatment.⁶ However, the fact is that tooth retention in middle-aged and older adults has created a new need and demand for dental care in those cohorts.⁷ These coincident but counter-vening trends have resulted in a decline in the severity of dental caries in most children while the need for dental care in middle-aged and older adults has increased.

With the fundamental change in the retention of teeth in the 20th century, the patterns of dental and oral diseases are also changing.

It must be recognized that dental caries has not declined for lower-income, certain minority and immigrant children (C.W. Douglass, D.M.D., Ph.D., et al., unpublished case study).⁸ This disparity in oral health status among children and adults has resulted in an estimated 30 percent of the U.S. population not receiving regular dental care.

As Americans’ oral health continues to improve, it is critically important that dental professionals identify innovative ways to address access to oral health care for underserved populations. Dental societies across the country as well as public health organizations will need to work together to develop creative methods to meet these oral health needs and improve the oral health of all Americans.

With age comes gingival recession and the exposure of root surfaces. Decayed and filled root surfaces increase from an average of 0.1 surfaces per person in late teen-age years to 3.5 surfaces per person in adults 80 years of age and older.⁹ In community-dwelling elders, increased retention of the natural dentition has been shown to be associated with a higher incidence of root caries.¹⁰ Also, high mutans streptococci counts in men have been shown to be associated with root caries.¹¹

Periodontal disease was also found to be greater in older patients who had been successful in retaining their natural dentition.¹⁰ Adults with more teeth had significantly greater periodontal pocket depths and loss of attachment. These higher disease rates translate into an increased number of dental office visits. This same large-scale study also showed that older adults with 25 or more natural teeth also made twice as many dental care visits as did those with less than 10 teeth. For 35 percent of these older patients, their most recent visit was not for regular maintenance care, but for necessary treatment of a specific dental problem.¹⁰

In addition, the treatment choices available today offer patients the opportunity to improve their self-esteem. "Smile makeovers" are considered to be "instant face-lifts" by some older adults. Whitening, orthodontics and other cosmetic dental options now have become treatment options that patients increasingly expect to receive after dental diseases are controlled. Hence, the "more teeth, more dental care demands" theory¹² debated in the 1980s seems to be coming true. As the members of our large and growing older adult population retain their teeth, they need and seek out more dental care than older adults who have fewer teeth.

	DIVERSITY AMONG DENTAL PRACTICES

TOP ABSTRACT AGE AND DIVERSITY THINK COHORTS TRENDS IN DISEASE PATTERNS DIVERSITY AMONG DENTAL PRACTICES ACCOUNTABILITY REFERENCES

 
With the diversity of dental patients has come a comparable diversity in dental practice. For the past 30 years, about one-tenth of dentists have been in specialty practice. As we move into the 21st century, however, there will be a marked increase in specialists—or at least it will seem so. This trend toward specialization is occurring because the number of graduates from dental schools has declined dramatically, from about 6,000 in the early 1980s to about 3,900 today. However, the number of specialty training positions has not declined and remains steady at about 1,200. Thus, about 1,200 out of 3,900 recent graduates are becoming specialists.¹³ Hence, eventually nearly one-third of all practicing dentists will be specialists.

Eventually nearly one-third of all practicing dentists will be specialists.

In addition to this fundamental increase in the proportion of dentists who will be trained as specialists, there is a trend in dental practice that reflects the demographic and disease pattern changes described above. Specifically, five types of practices with certain emphases are emerging as a result. Each type is discussed as follows.

Practices limited to esthetic dentistry. A strong trend that will continue well into the 21st century is the esthetic practice. The baby boom generation and the life expectations of relatively affluent cohorts are providing more and more dental patients who value not only oral health, but also an attractive smile for their self-esteem and its social advantages. These cohorts will be active dental patients for many decades to come because they will live even longer than today’s older patients.

Practices limited to providing geriatric dental services. Practices focusing on treating older adults will increase. In metropolitan areas it is already common to find several dentists—usually relatively recent graduates—who practice exclusively in nursing homes and senior center programs. A significant expansion is currently under way in the building of assisted living facilities. This trend, along with the development of larger retirement villages, will create new opportunities for dentists who are interested in limiting their practice to older adult patients by locating their practice in or near these residential health facilities.

Practices limited to providing diagnostic services. With the development of new diagnostic technologies and the ADA’s approval of radiology as an official specialty of dentistry, dental practices limited to diagnostic services will start to emerge. In the future, technologies such as fiber-optic transillumination and various fluorescence methodologies may provide dentists with the ability to detect dental caries and periodontal disease much earlier than the traditional methods of radiographs with a mirror and explorer examination.

As new pharmacotherapies prove to be effective in remineralizing tooth enamel and preventing gingival attachment loss, early diagnosis will be sought out by more patients who view oral health as essential to their overall health.

Group practices. Group practices will increase in number. Sometimes owned by non-dentist investors, group practices have sprung up in various parts of the United States. Group practice as a publicly traded company provides another avenue for the delivery of oral health services as well as a new business model. Dentist-owned group practices, both specialty and multispecialty, also will increase in number in the 21st century.

HMOs. Dental benefits included in HMO services may increase. Dentists participating in HMOs will find themselves with many older adult patients expecting that their dental disease be managed economically, which means prevention and early primary care services. As these practices develop, they are likely to be early adopters of new technologies that can prevent dental caries and periodontal disease or treat these diseases in a conservative primary care format. For example, a positive diagnostic periodontal test will enable patients to receive additional periodontal services.

	ACCOUNTABILITY

TOP ABSTRACT AGE AND DIVERSITY THINK COHORTS TRENDS IN DISEASE PATTERNS DIVERSITY AMONG DENTAL PRACTICES ACCOUNTABILITY REFERENCES

 
The stage is set for a confluence of trends as we head into the 21st century:

– population growth;

– aging and diversity of patients;

– retention of natural dentition;

– greater awareness of oral health as a component of overall health;

– new technologies for early diagnosis;

– new technologies for early therapy;

– new technologies for restorative treatment;

– increased specialization;

– the emergence of dental practices that target specific types of patients;

– the Internet as a communication/information tool for patients and dental professionals;

– fewer practicing dentists.

A more sophisticated patient population is expected to be more aggressive in its expectations of dental care providers. Today’s dental patients reflect the more litigious society in which we live. Also, the dental care payers are beginning to ask for outcomes of care that measure the effectiveness of the services provided. For example, will the placement of a sealant on a permanent molar prevent occlusal caries and the subsequent costs of re-restoration?

The dental profession of the 21st century may be held more accountable for patient care than ever before. As the science base moves forward and technological advances are made, patients’ expectations of the dental profession will rise. The dental office of the future will build on these technological advances to improve the delivery of dental care (Figure 3). The Internet is stimulating this trend as patients are directly accessing information on new dental care technologies and treatment methods, then coming to their dental appointments with questions on these new therapies. Thus, dental professionals will be held more accountable for the quality of their dental care and for the skills with which they can communicate diagnoses and treatment needs than ever before.

View larger version (104K): [in this window] [in a new window]   Figure 3. Dental offices of the future will rely more heavily on technology as diagnostic, delivery and patient education aids. This operatory has a clinical microscope, video monitors, cameras, computers, digital radiography and other technological aids.