menu-iconMore mobile-close-icon
Skip Navigation
Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas.
Bibliographic Source(s)
Rethman MP, Carpenter W, Cohen EE, Epstein J, Evans CA, Flaitz CM, Graham FJ, Hujoel PP, Kalmar JR, Koch WM, Lambert PM, Lingen MW, Oettmeier BW Jr, Patton LL, Perkins D, Reid BC, Sciubba JJ, Tomar SL, Wyatt AD Jr, Aravamudhan K, Frantsve-Hawley J, Cleveland JL, Meyer DM, American Dental Association Council on Scientific Affairs Expert Panel [trunc]. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc. 2010 May;141(5):509-20. [51 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Oral squamous cell carcinomas

Note: Squamous cell carcinomas of the lips and oropharynx are not included in this guideline.

Guideline Category
Evaluation
Screening
Clinical Specialty
Dentistry
Oncology
Otolaryngology
Pathology
Intended Users
Dentists
Guideline Objective(s)
  • To provide a critical evaluation and summary of the relevant scientific evidence and to provide recommendations that will assist clinicians with their decision-making process
  • To address the potential benefits and potential risks of screening for oral squamous cell carcinomas and the use of adjunctive screening aids to visualize and detect potentially malignant and malignant oral lesions
Target Population

General population of all ages, particularly patients who use tobacco or who are heavy consumers of alcohol

Interventions and Practices Considered

Screening

  1. Health history
  2. Visual and tactile examination of the oral cavity
  3. Use of devices intended to assist in lesion detection

Evaluation

  1. Follow-up of seemingly innocuous and suspicious lesions
  2. Communicating risks and benefits of early diagnosis to patients
  3. Lesion detection and assessment
  4. Use of visual aids
  5. Transepithelial cytology
  6. Surgical biopsy
  7. Specimen analysis
Major Outcomes Considered
  • Mortality and morbidity due to squamous cell cancer
  • Survival rate
  • Sensitivity and specificity of devices intended to assist in lesion detection
  • False-positive, false-negative, and positive predictive value of screening tests
  • Incidence of squamous cell carcinomas

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Staff members of the American Dental Association (ADA) Center for Evidence-Based Dentistry searched MEDLINE through PubMed to identify systematic reviews that addressed the four clinical questions. (For information about the clinical questions and detailed methods, refer to Appendix 1 in the supplemental data to the online version of the original guideline [see "Availability of Companion Documents" field].) On the basis of the inclusion and exclusion criteria, they identified five systematic reviews. They conducted a second search to identify clinical studies published after the last search date within the systematic reviews. They identified four additional clinical studies. Appendix 1 in the supplemental data online (see "Availability of Companion Documents" field) provides a detailed description of the search methodology and the inclusion and exclusion criteria, as well as a list of excluded publications.

Number of Source Documents

Five systematic reviews and four clinical studies were used as a basis for developing the recommendations.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Grade Category of Evidence
Ia Evidence from systematic reviews of randomized controlled trials
Ib Evidence from at least one randomized controlled trial
IIa Evidence from at least one controlled study without randomization
IIb Evidence from at least one other type of quasiexperimental study, such as time series analysis or studies in which the unit of analysis is not the individual
III Evidence from nonexperimental descriptive studies, such as comparative studies, correlation studies, cohort studies and case-control studies
IV Evidence from expert committee reports or opinions or clinical experience of respected authorities

*Amended with permission of the British Medical Journal (BMJ) Publishing Group from Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. Brit Med J 1999;318(7183):593-6.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Data Synthesis and Critical Appraisal

The panel performed a qualitative synthesis of data from the included studies in a narrative format. For the included studies, they performed quality assessment of the individual articles by using standard U.S. Preventive Services Task Force methodology for determining internal and external validity. (For information about the quality assessment, refer to Appendix 2 of the supplemental data to the online version of this guideline [see "Availability of Companion Documents" field].) The panel asked the authors of a systematic review of adjunctive screening devices to update the results of their systematic review with data from the three included clinical studies of screening devices. (For information about the update, refer to Appendix 3 of the supplemental data to the online version of this article [see "Availability of Companion Documents" field].)

Methods Used to Formulate the Recommendations
Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations

The American Dental Association (ADA) Council on Scientific Affairs convened a panel to evaluate the available evidence regarding oral cancer screening and the use of adjuncts. The Council selected panelists on the basis of their expertise in the relevant subject matter. At a workshop held at ADA Headquarters April 13-15, 2009, the panel evaluated the published evidence and developed evidence-based clinical recommendations for oral cancer screening and the use of adjuncts.

Grading Evidence Statements and Clinical Recommendations

On the basis of the included studies, the panel developed evidence statements and graded them according to a system developed by Shekelle and colleagues (see "Rating Scheme for the Strength of the Evidence" field). The panel developed clinical recommendations based on its interpretation of this evidence. They classified clinical recommendations according to the strength of the evidence that formed the basis for the recommendation, again by using a system modified from that of Shekelle and colleagues (see "Rating Scheme for the Strength of the Recommendations" field). The classification of the recommendation directly reflects the level of scientific evidence that supports the recommendation.

Process for Developing Clinical Recommendations

When the panel was unable to reach a consensus when translating evidence into clinically relevant recommendations, it used a majority vote to make final determinations.

Rating Scheme for the Strength of the Recommendations
Classification Strength of Recommendations
A Directly based on grade I evidence
B Directly based on grade II evidence or extrapolated recommendation from grade I evidence
C Directly based on grade III evidence or extrapolated recommendation from grade I or II evidence
D Directly based on grade IV evidence or extrapolated recommendation from grade I, II, or III evidence

*Amended with permission of the British Medical Journal (BMJ) Publishing Group from Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. Brit Med J 1999;318(7183):593-6.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The panel submitted its clinical recommendations for comment to both internal and external scientific experts and organizations. After reviewing all submitted remarks, the panel revised its recommendations where appropriate. (For information about the external reviewers, see Appendix 4 of the supplemental data to the online version of this guideline [see "Availability of Companion Documents" field].) The American Dental Association (ADA) Council on Scientific Affairs approved the final clinical recommendations.

Recommendations

Major Recommendations

The grades of evidence (Ia-IV) and the classification of recommendations (A-D) are defined at the end of the "Major Recommendations" field.

Recommendations of the American Dental Association Council on Scientific Affairs Expert Panel on Screening for Oral Squamous Cell Carcinomas,* based on evidence
Screening for oral cancer is one component of a thorough hard-tissue and soft-tissue examination that follows patient history and risk assessment
TOPIC RECOMMENDATION CLASSIFICATION
Screening during routine examinations† The panel suggests that clinicians remain alert for signs of potentially malignant lesions or early-stage cancers in all patients while performing routine visual and tactile examinations, particularly for patients who use tobacco or who are heavy‡ consumers of alcohol D
Follow-up for seemingly innocuous lesions For seemingly innocuous lesions, the panel suggests that clinicians follow up in 7 to 14 days to confirm persistence after removing any possible cause to reduce the potential for false-positive screening results D
Follow-up for lesions that raise suspicion of cancer and those that are persistent For lesions that raise suspicion of cancer or for lesions that persist after removal of a possible cause, the panel suggests that clinicians communicate the potential benefits and risks of early diagnosis

Considerations include the following:
  • That even suspicious lesions identified during the course of a routine visual and tactile examination may represent false positives
  • That clinical confirmation (a second opinion) can be sought from a dental or medical care provider with advanced training and experience in diagnosis of oral mucosal disease so as to reduce the potential for a false-positive or false-negative oral cancer screening result
  • That a malignancy or nonmalignancy can be confirmed only via microscopic examination that requires a surgical biopsy
  • that a decision to pursue a biopsy to confirm the presence or absence of malignancy should be made in the context of informed consent
D
Use of lesion assessment devices Although transepithelial cytology has validity in identifying disaggregated dysplastic cells, the panel suggests surgical biopsy for definitive diagnosis D

*The expert panel was convened in April 2009 to address the benefits and limitations of oral cancer screening and the use of adjunctive screening aids to visualize and detect potentially malignant and malignant oral lesions.
†There is insufficient evidence that use of commercial devices for lesion detection that are based on autofluorescence or tissue reflectance enhance visual detection of potentially malignant lesions beyond a conventional visual and tactile examination.
‡Heavy alcohol consumption is defined as follows: for men, consumption of an average of more than two drinks per day; for women, consumption of an average of more than one drink per day.

Definitions:

Grade Category of Evidence
Ia Evidence from systematic reviews of randomized controlled trials
Ib Evidence from at least one randomized controlled trial
IIa Evidence from at least one controlled study without randomization
IIb Evidence from at least one other type of quasiexperimental study, such as time series analysis or studies in which the unit of analysis is not the individual
III Evidence from nonexperimental descriptive studies, such as comparative studies, correlation studies, cohort studies and case-control studies
IV Evidence from expert committee reports or opinions or clinical experience of respected authorities

*Amended with permission of the British Medical Journal (BMJ) Publishing Group from Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. Brit Med J 1999;318(7183):593-6.

 

Classification Strength of Recommendations
A Directly based on grade I evidence
B Directly based on grade II evidence or extrapolated recommendation from grade I evidence
C Directly based on grade III evidence or extrapolated recommendation from grade I or II evidence
D Directly based on grade IV evidence or extrapolated recommendation from grade I, II, or III evidence

*Amended with permission of the British Medical Journal (BMJ) Publishing Group from Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. Brit Med J 1999;318(7183):593-6.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate early identification of oral squamous cell carcinomas

Potential Harms
  • Screening may reveal highly aggressive life-threatening cancers whose outcome may not have been changed by early detection—that is, for which treatment would be futile. In addition, screenings may falsely identify nondiseased sites as diseased and may detect disease that, if undetected, might not ever interfere with a patient's life. The latter two scenarios can result in needless worry, unnecessary interventions and wasted resources.
  • People whose screening results are negative for potentially malignant lesions (lesions that are clinically occult or lesions that do not raise suspicion for cancer) but who actually have cancer (false negatives) may experience a false sense of security and may delay receiving cancer therapy.

Qualifying Statements

Qualifying Statements
  • The clinical recommendations in this article, which presents a critical evaluation and summary of the relevant scientific evidence, do not represent a standard of care. Instead, this report is intended to assist the clinician in the decision-making process. Its clinical recommendations should be integrated with the practitioner's professional judgment and the individual patient's needs and informed references.
  • Although the panel formulated these recommendations on the basis of careful review of published scientific evidence, the panel acknowledges that the current literature related to oral cancer is not robust.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Pocket Guide/Reference Cards
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Rethman MP, Carpenter W, Cohen EE, Epstein J, Evans CA, Flaitz CM, Graham FJ, Hujoel PP, Kalmar JR, Koch WM, Lambert PM, Lingen MW, Oettmeier BW Jr, Patton LL, Perkins D, Reid BC, Sciubba JJ, Tomar SL, Wyatt AD Jr, Aravamudhan K, Frantsve-Hawley J, Cleveland JL, Meyer DM, American Dental Association Council on Scientific Affairs Expert Panel [trunc]. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc. 2010 May;141(5):509-20. [51 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 May
Guideline Developer(s)
American Dental Association - Professional Association
Source(s) of Funding

The work of this panel was commissioned by the Council on Scientific Affairs and was funded jointly by the American Dental Association (ADA) and the Centers for Disease Control and Prevention (CDC).

Guideline Committee

American Dental Association Council on Scientific Affairs Expert Panel on Screening for Oral Squamous Cell Carcinomas

Composition of Group That Authored the Guideline

Panel Members: Michael P. Rethman, DDS, MS; William Carpenter, DDS, MS; Ezra E.W. Cohen, MD; Joel Epstein, DMD, MSD, FRCD(C), FDS RCS(Ed); Caswell A. Evans, DDS, MPH; Catherine M. Flaitz, DDS, MS; Frank J. Graham, DMD; Philippe P. Hujoel, MSD, PhD; John R. Kalmar, DMD, PhD; Wayne M. Koch, MD; Paul M. Lambert, DDS; Mark W. Lingen, DDS, PhD; Bert W. Oettmeier Jr., DDS; Lauren L. Patton, DDS; David Perkins, DMD; Britt C. Reid, DDS, PhD; James J. Sciubba, DMD, PhD; Scott L. Tomar, DMD, DrPH; Alfred D. Wyatt Jr., DMD; Krishna Aravamudhan, BDS, MS; Julie Frantsve-Hawley, RDH, PhD; Jennifer L. Cleveland, DDS, MPH; Daniel M. Meyer, DDS

Financial Disclosures/Conflicts of Interest

The panel comprised 20 people who represented a broad range of expertise. Each panelist completed a standard conflict-of-interest questionnaire.

Dr. Carpenter has received compensation from Oral CDx Laboratories, Suffern, N.Y., for lectures he has presented. Dr. Epstein is conducting an ongoing study with Zila Pharmaceuticals, Phoenix, served on the company's medical advisory board until 2007 and has given presentations supported by the company. Dr. Flaitz is a research investigator in a clinical trial funded by Trimira, Houston, investigating the use of the Identafi 3000 for the detection of oral lesions, and is a funded presenter for educating the public about this new device; she was a funded lecturer for Oral CDx Laboratories; she received "in kind" products to assist in teaching and for continuing education programs from Oral CDx BrushTest (CDx Laboratories), ViziLite (Zila Pharmaceuticals), Identafi 3000 (Trimira), MicroLux/DL (AdDent, Danbury, Conn.) and VELscope (LED Dental, Burnaby, British Columbia, Canada). Dr. Sciubba has received compensation from Oral CDx Laboratories for lectures he has presented. Dr. Wyatt has lectured for and was compensated financially by LED Dental.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Dental Association Web site External Web Site Policy.

Print copies: Available from the American Dental Association, 211 E. Chicago Avenue, Chicago, IL 60611

Availability of Companion Documents

The following is available:

  • Appendixes to evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. A report of the American Dental Association Council on Scientific Affairs; 2010. 29 p. Electronic copies: Available in Portable Document Format (PDF) from the American Dental Association (ADA) Web site External Web Site Policy.

Print copies: Available from the American Dental Association, 211 E. Chicago Avenue, Chicago, IL 60611

The following is also available:

  • Screening for oral cancer. Chairside guide. 2 p. Electronic copies: Available from the ADA Web site External Web Site Policy.
Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on January 7, 2011. The information was verified by the guideline developer on February 14, 2011.

Copyright Statement

This NGC summary (abstracted American Dental Association Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Content contained within the original guideline and/or the NGC Summary of this guideline may not be used for commercial and/or product endorsement.

All other copyright rights in the American Dental Association Guidelines are reserved by the American Dental Association. For information concerning terms governing downloading, use, and reproduction of these guidelines contact the American Dental Association.

The American Dental Association reserves the right to review NCG-developed content pertaining to American Dental Association's identified guidelines, and to approve same prior to its publication on the NGC Web site.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...