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Introduction: Over the past 2 decades in the U.S., the reduced burden and narrowed inequality in oral health among children are in stark contrast with the high burden and widening inequality in adult oral health. This study aimed to explore the burden, trends, and inequalities of untreated caries in permanent teeth in the U.S. during 1990-2019., Methods: Data on burden of untreated caries in permanent teeth were extracted from the Global Burden of Disease Study 2019. A set of advanced analytical methods were applied to provide an in-depth characterization of the epidemiologic profile of dental caries in the U.S. Analyses were conducted during April 2022-October 2022., Results: In 2019, age-standardized incidence and prevalence of untreated caries in permanent teeth were respectively 39,111.7 (95% uncertainty interval=35,073.0-42,964.9) and 21,722.5 (95% uncertainty interval=18,748.7-25,090.3) per 100,000 person-years. Population growth was the primary driver of the increased caries cases, which contributed 31.3% and 31.0% of the increase in the number of incident and prevalent caries cases, respectively, during 1990-2019. The highest caries burden was noted in Arizona, West Virginia, Michigan, and Pennsylvania. The slope index of inequality remained stable (p=0.076), whereas the relative index of inequality increased significantly (average annual percent change=0.04, p<0.001) in the U.S. The burden of untreated caries in permanent teeth remained significant with a widening cross-state inequality during 1990-2019., Conclusions: The oral healthcare system in the U.S. needs to prioritize health promotion and prevention with a focus on expanding access, affordability, and equity., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)