ADA guideline prioritizes clinical exam over vital staining in early oral cancer detection

Second set of recommendations published April 6 in JADA

The latest recommendations to be released from the American Dental Association’s living guideline on early oral cancer detection reiterate the importance of clinical exams while advising against the use of vital staining adjuncts to evaluate the need for biopsy.

“Oral cavity and oropharyngeal cancers are common malignancies and are associated with significant morbidity and mortality,” said Mark Lingen, D.D.S., Ph.D., professor of pathology at the University of Chicago Medicine and former member of the ADA Council on Scientific Affairs. “Dental professionals are uniquely qualified to perform regular conventional and visual tactile exams to identify precancerous and cancerous lesions at earlier clinical stages, thereby improving outcomes.”

These recommendations and good practice statements on vital staining adjuncts — published online April 6 and in the June issue of The Journal of the American Dental Association — are the second set to be released from the living guideline. They address the use of special staining liquids, specifically toluidine blue, that highlight areas in the mouth that appear to show abnormal signs.

The statements reaffirm that clinicians should perform a comprehensive extraoral and intraoral clinical exam on all adults, communicate its role in the early detection of mucosal abnormalities, and obtain patients’ updated medical, social and dental histories. The guideline also maintains that a punch or scalpel biopsy followed by histopathological assessment remains the first choice for reaching a definitive diagnosis of oral squamous cell carcinoma or oral potentially malignant disorders.

The guideline includes conditional recommendations against the use of vital staining adjuncts to determine the need for biopsy or specialist referral in adults with any mucosal abnormality in the oral cavity or on the lip or to screen for the potential need for biopsy or referral among asymptomatic adults with no clinically evident oral mucosal abnormality in the oral cavity or on the lip.

The guideline states that evidence does not support the use of vital staining adjuncts to determine which lesions require biopsy or referral, reliance on these adjuncts may lead to unnecessary procedures or delayed diagnosis, and clinicians should perform a timely biopsy or referral if they identify mucosal abnormalities.

Because the recommendations in the guideline are considered conditional — meaning they are based on the limited evidence available at this time — different courses of action could be appropriate based on clinicians’ and patients’ values and preferences, according to the guideline.

“Based upon the currently available science, we do not recommend the use of vital staining as a screening adjunct to aid in the decision-making process of determining which patients require a biopsy to diagnose oral potentially malignant disorders and oral cavity cancer,” Dr. Lingen said.

This living guideline on the early detection of oral squamous cell carcinoma and potentially malignant disorders is an update to a 2017 clinical practice guideline on the evaluation of potentially malignant disorders, including oral cancer.

Guidelines developed as part of the ADA Living Guideline Program, established in 2025, provide oral health care providers and patients with more frequent evidence-informed recommendations to advance oral and overall health. The program upholds the methodological rigor of traditional guidelines, but living guidelines are continually updated as new evidence becomes available.

The guideline development was led by a team of methodologists from the Center for Integrative Global Oral Health at the University of Pennsylvania School of Dental Medicine. Its recommendations were formed with rigorous methodology — including a living systematic review and a scoping review — by an expert multidisciplinary guideline panel chaired by Dr. Lingen. Public comment from oral health care professionals and extensive interest-holder engagement also contributed to the development of these recommendations.

To read the full set of recommendations and good practice statements online and access an interactive infographic as well as other resources, visit ADA.org/OralCancerGuideline.

The guideline is also available at JADA.ADA.org. It has been published in a new section of JADA called JADA Evidence, which will present living guidelines as they are developed to help bring the latest oral health care recommendations to clinicians.

The first set of recommendations on cytology adjuncts was published in March. Future recommendations from the guideline will address light-based adjuncts and salivary tests. They are expected to be published this year in JADA Evidence.

April is Oral Cancer Awareness Month. For more ADA resources related to oral cancer, visit the Oral Health Topics webpage on cancer.