U.S. health problems (the national bill for dental services in 1988 was $30+ billion).40 With the projected increase in the number of dentate older adults, ability to pay may become an increasingly critical factor.51 Dentate older adults are seeking and receiving complex, expensive dental services at a proportionately greater rate than younger adults.19 Although preventive services are generally less expensive than restorative procedures, they nevertheless represent a basic cost in personal health care services. Considerable restorative work (secondary prevention) will be needed by upcoming cohorts to maintain a functional dentition; as a result, the total absence of insurance or prepayment mechanisms, and the failure of many reimbursement systems to acknowledge and support preventive services, may create significant barriers to regular use of dental services in the over-50 population.15,19
Many direct risk factors for common oral diseases of older adults are known. The reduction of those factors, or their actual elimination, is possible through appropriate preventive self-care, elimination of high-risk behaviors, professionally provided preventive, diagnostic, and therapeutic care, and a supportive environment.
At present, there is no consensus regarding secondary prevention of oral cancer. Oral cancer screening procedures have yet to be tested for sensitivity and false-positive rates; there is also concern that a complete oral exam is too impractical for physicians to perform with every periodical visit.48
All high clinical suspicions of oral cancer indicate the need for biopsy, regardless of other diagnostic tools. Most oral lesions are detected when they are in an advanced state and are easily seen owing to their large size. Because the probability of developing oral cancers varies by location and behavior, early detection of oral cancers, when lesions are smaller, depends on an acute sense of the high-risk areas of the mouth and the connection between risk behaviors (e.g., smoking and drinking) and the locus of the lesions.
For high-risk groups, a stronger consensus exists regarding primary and secondary prevention. Good evidence suggests that an independent and synergistic risk exists for oral cancer as a result of smoking and excessive alcohol use. Tobacco chewing has also been linked to oral cancer. Patients who are at risk because of these behaviors should be counseled against them by their health care providers. These high-risk patients should be screened during periodical health exams and should be examined annually.