In 2017, an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs published a systematic review/meta-analysis and clinical practice guideline called the "Evidence-Based Clinical Practice Guideline for the Evaluation of Potentially Malignant Disorders in the Oral Cavity."27, 28
The goal of this clinical practice guideline is to inform clinicians about the potential use of adjuncts as triage tools for the evaluation of lesions, including potentially malignant disorders, in the oral cavity. Among the guideline's recommendations:
- Clinicians should obtain an updated medical, social, and dental history and perform an intraoral and extraoral conventional visual and tactile examination in all adult patients.
- For patients with suspicious lesions, clinicians should immediately perform a biopsy of the lesion or refer the patient to a specialist.
- Salivary and light-based adjuncts are not recommended for evaluating lesions for malignancy.
The U.S. Preventive Services Task Force (USPSTF)29
concluded in 2013 that “current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults,” although the statement specifically clarifies that, “This recommendation is intended for primary care providers and does not pertain to dental providers or otolaryngologists. Dental care providers and otolaryngologists may conduct a comprehensive examination of the oral cavity and pharynx during the clinical encounter.”
ADA Current Dental Terminology (CDT) code D0120 for “periodic oral evaluation” (established patient) includes “an oral cancer evaluation … where indicated.” CDT code D0150 for “comprehensive oral evaluation” (new or established patient) also includes “an evaluation for oral cancer where indicated.” The National Institute for Dental and Craniofacial Research (NIDCR)6
provides a protocol for dental practitioners for an oral cancer examination based on the standardized oral examination method recommended by the World Health Organization. The NIDCR examination method is “consistent with those followed by the Centers for Disease Control and Prevention and the National Institutes of Health” and requires adequate lighting, a dental mouth mirror, two 2" x 2" gauze squares, and gloves and should take approximately 5 minutes.6
The NIDCR provides the examination protocol in poster form
and also has a pamphlet
on oral cancer for patients and a patient education resource
for oral cancer and the oral cancer exam; these items are not copyrighted and can be reproduced freely. An additional resource is the video posted by the ADA demonstrating the evaluation of a patient for potentially malignant disorders
, showing inspection and palpation elements of the intra- and extraoral examination.
suggests that a thorough head and neck examination should be a routine part of each patient's dental visit, as follows. Clinicians should be particularly vigilant in checking those who use tobacco or excessive amounts of alcohol.
- Examine your patients using the head and neck examination protocol described by the NIDCR.
- Take a history of their alcohol and tobacco use.
- Inform your patients of the association between tobacco use, alcohol use, and oral cancer.
- Follow-up to make sure a definitive diagnosis is obtained on any possible signs or symptoms of oral cancer.
A 2014 ADA Policy statement on “Early Detection and Prevention of Oral Cancer”30
reads as follows:
- Resolved, that the American Dental Association recognizes that early oral cancer diagnosis has the potential to have a significant impact on treatment decisions and outcomes, and supports routine visual and tactile examinations, particularly for patients who are at risk including those who use tobacco or who are heavy consumers of alcohol, and be it further
- Resolved, that the Association supports state and local Association sponsored education activities to promote the prevention and early detection of oral cancer to those who use tobacco, alcohol or both.
Given that mortality rates from OC/OP-SCC have been fairly stable,31
it has been posited that earlier detection of oral cancers will improve prognosis. A 2015 systematic review and meta-analysis by Seoane et al.32
found that a longer time interval from a patient’s first symptom to referral for diagnosis was a “risk factor for advanced stage and mortality of oral cancer.”
A number of adjuncts to the standard clinical examination have been developed and are intended to improve disease detection. These include oral brush cytology, toluidine blue staining, and light-based detection systems to increase the visibility of oral mucosal lesions or provide real-time data on suspicious mucosal lesions.33
Diagnostic performance in clinical studies has been inconsistent because results vary according to study settings and the sample populations enrolled.33
As noted in the 2017 ADA clinical practice guideline,27, 28
it is not yet clear whether these ancillary tests are helpful in triaging which patients need diagnostic or therapeutic follow-up, in part because these tests also cause false-positive results. Diagnostic adjuncts have been evaluated primarily in referral clinic settings or cancer centers and in patients at high baseline risk of disease.33
Data from studies in general clinic settings and in patients at low baseline risk of disease are more limited and additional data are needed to characterize test performance in these populations and settings.33