ADA reaffirms importance of clinical exams in early oral cancer detection

First living guideline recommendations explain limited indications for cytology adjuncts

Clinical oral exams remain foundational to the early detection of oral cancer and cytology adjuncts should only be used in certain circumstances to help inform the need for biopsy, according to updated guideline recommendations and good practice statements from the American Dental Association.

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.

“Screening and early detection of oral potentially malignant disorders and oral cavity cancer can improve patient outcomes,” 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.

This set of recommendations and good practice statements, published in the March issue of The Journal of the American Dental Association, is the first to be released as part of a living guideline on the early detection of oral squamous cell carcinoma and potentially malignant disorders. The living guideline is an update to a 2017 clinical practice guideline on the evaluation of potentially malignant disorders, including oral cancer.

Clinical practice 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 updated as new evidence becomes available.

“Because new evidence is evaluated frequently, living guidelines answer critical clinical questions as they emerge,” said Jennifer Holtzman, D.D.S., chair of the ADA Council on Scientific Affairs.

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 — by an expert multidisciplinary guideline panel chaired by Dr. Lingen. Public comment from oral health care professionals also contributed to the development of these recommendations.

Findings in the guideline recommend against the use of cytology adjuncts to determine the need for biopsy or referral in adults with abnormal tissue in the oral cavity or on the lip because the tests — which involve collecting a sample of cells from a mucosal abnormality with a brush — could produce false positive results. They also recommend against using adjuncts to screen asymptomatic adults without clinically evident mucosal abnormalities, as evidence supporting this use is lacking.

Another recommendation suggests that clinicians offer a cytology adjunct to adults with clinically worrisome mucosal abnormalities only when a biopsy is not possible, advisable or indicated. The purpose of the test would be to inform — not determine — decisions about biopsy or referral.

“Based upon the currently available science, we do not recommend the use of cytology 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. “In certain limited clinical scenarios where a biopsy is not feasible, cytology may be an appropriate interim preliminary triage step in the overall evaluation of a patient.”

A good practice statement from the guideline advises that negative cytology results do not rule out disease and if a mucosal abnormality persists or progresses despite a negative result, clinicians should perform a biopsy or refer the patient to a specialist to avoid delayed diagnosis.

To read the full guideline online and access an interactive infographic with the recommendations and 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.

Future sets of recommendations from the guideline will address vital staining adjuncts, light-based adjuncts and salivary tests. They are expected to be published this year in JADA Evidence.

Other articles in the March issue of JADA discuss adults with diabetes and periodontal disease, resources for dental care in young children, and dental implant failure and sarcoidosis.

Every month, JADA articles are published online at JADA.ADA.org. ADA members can access JADA content with their ADA username and password.