For decades, our understanding of oral health in the United States has been built largely on surveys and samples. The nation’s gold standard—the CDC’s NHANES—examines roughly 25,000 adults per cycle using a questionnaire and visual exams. But that approach leaves out one of the most important parts of the clinical picture: the dental x-ray.
The Pearl Oral Health Index was created as the first-ever report aimed at filling that gap. From April 2024 to March 2026, our FDA-cleared AI analyzed 26 million x-rays from 15 million patients across all 50 states, creating the largest population-scale view of oral health through radiographic data to date.
Here are five surprising findings that reveal a clearer picture of America’s teeth:
1. America’s cavity problem is at least 4.5x worse than federal data suggests
According to NHANES, about 21% of adults have untreated decay based on what can be seen during a visual exam with a mirror and explorer. But x-rays reveal what the eye cannot: decay can be present after 30-60% mineral loss, long before it becomes visible.
So when radiographic findings are included, the true rate of untreated decay is 4.5x higher.
2. In dental deserts, patients lose 40% more teeth
We compared patient data against a registry of nearly 181,000 dental practices and 296,000 dentists to understand how access impacts outcomes. In ZIP codes without a dental practice, extraction rates are significantly higher than in better-served communities.
But the difference is not that patients in dental deserts have dramatically worse disease. Rather, it’s about what happens after disease is found: more extractions, fewer restorations.
3. Women are 28% more likely to visit the dentist than men
In the U.S., women go to the dentist more often than men. But in countries where access to care is universal, that gap largely vanishes. Under the U.K.’s National Health Service, for example, women and men seek dental care at nearly identical rates.
Once in the chair, oral health looks similar regardless of sex. Across 9.5 million patients, women averaged 3.87 decayed teeth versus 4.03 for men. Untreated decay rates were also close: 31.4% for women and 33.9% for men.
4. Young adults have the most untreated disease of any age group
Among adults ages 18-24, 52% of all dental disease is untreated. That share remains above 50% until the mid-30s, when restorations finally begin to outnumber untreated decay.
By age 75 and older, only 28% of disease remains untreated, but the overall burden is much higher, reaching 19.1 affected teeth out of 28. While disease accumulates with age, older adults manage it more than younger patients.
5. Four teeth carry nearly a third of all restorations
The first molars (#3, #14, #19, #30) make up just 14% of the teeth in the mouth but account for 24% of all detected decay and 31% of all restorations.
First molars are especially vulnerable because they’re the first permanent teeth to grow in, typically around age 6, and their anatomy makes them more prone to decay. The median age of first decay detection is 17 for first molars, compared to 23 for lower incisors. That six-year gap offers a clear prevention window that can help keep patients on a healthier path for the years to come.
Why we built the Pearl Oral Health Index
Dentistry has never had a population-scale view of what is actually happening in patients' mouths. Our AI operates alongside more than 50,000 clinicians, making it possible to see oral health at a resolution that hasn’t existed before.
The Pearl Oral Health Index is our effort to put that data to work as an accessible resource. The findings, in some places, are more sobering than existing public data has shown, but as clinicians are well aware: you can’t fix what you can’t see.
For the first time, we can finally see a clear picture of American oral health — and the depth of the challenges waiting to be taken on.