Early detection of oral cancer and oral potentially malignant disorders


About 6500 cases of oral cavity squamous cell carcinoma (OSCC) are diagnosed in the UK each year. However, despite improvements in the management of oral cancer survival rates have remained largely unchanged over recent decades. The early identification of patients with OSCC and a range of oral conditions (leukoplakia, erythroplakia, proliferative verrucous leukoplakia, oral lichen planus/oral lichenoid lesions, oral submucous fibrosis, and actinic keratosis) collectively referred to as oral potentially malignant disorders (OPMD) is considered important in improving survival rates as late presentation is a factor.

The aim of this Cochrane review update was to estimate the diagnostic test accuracy of conventional oral examination, vital rinsing, light-based detection, mouth self-examination, remote screening, and biomarkers, used singly or in combination, for the early detection of OPMD or OSCC in apparently healthy adults.


Searches were conducted in the Cochrane Oral Health’s Trials Register, Medline, Embase, the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform with no restrictions on the language or date of publication. Studies reporting diagnostic test accuracy in detecting OPMD or OSCC as noted above were considered.  Two reviewers screened and selected studies extracted data and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Study sensitivity and specificity was reported, and overall certainty of the evidence was assessed using GRADE.


  • 18 studies involving 72,202 patients were included.
  • 10 studies evaluated conventional oral examination (COE), 4 mouth self-examination (MSE), 3 remote screening and one COE with vital rinsing compare with COE alone.
  • Data could not be pooled because of the heterogeneity of the included studies.
  • In the 7 studies with a prevalence of 10% or lower (comparable to the general population) [Low certainty evidence]: –
    • Sensitivity estimates varied from 0.50(95%CI: 0.07 to 0.93) to 0.99 (95%CI: 0.97 to 1.00)
    • Specificity estimates ranged from 0.94(95%CI: 0.88 to 0.97) to 0.99 (95%CI: 0.98 to 1.00).
  • Evidence for mouth self-examination and remote screening was more limited and of very low certainty
  • Evidence for vital rinsing (toluidine blue) as an adjunct to COE compared to COE alone was considered to be of moderate certainty.
  • No studies assessing blood or saliva tests met the inclusion criteria.


The authors concluded: –

There is a lack of high-certainty evidence to support the use of screening programmes for oral cavity cancer and OPMD in the general population. Frontline screeners such as general dentists, dental hygienists, other allied professionals, and community healthcare workers should remain vigilant for signs of OPMD and OSCC.


This Cochrane review updates an earlier version (Dental Elf – 25th Nov 2013) and adds 5 additional studies. Owing to the marked variations in the studies in prognostic risk factors, the nature of the tests, personnel conducting the tests and the verification of both test negative, and test positive patients no pooling of data was undertaken.  The findings of the review suggest that COE has a variable degree of sensitivity (greater than 0.70 in six of the 10 studies), and a consistently high value for specificity greater than 0.90 in eight studies).  However, there are methodological shortcomings in the included studies and additional research is needed on COE and adjunctive tests. For while early identification of OSCC can result in reduced morbidity and improved survival rates it is important to remember that the natural history of OSCC is not fully understood, and not all OPMDs undergo malignant transformation. Consequently, until more robust data is available while performing routine oral examinations health care professionals should remain vigilant for the signs of OSCC and OPMDs.


Primary Paper

Walsh T, Warnakulasuriya S, Lingen MW, Kerr AR, Ogden GR, Glenny A-M, Macey R. Clinical assessment for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database of Systematic Reviews 2021, Issue 12. Art. No.: CD010173. DOI: 10.1002/14651858.CD010173.pub3. PMID: 34891214

Other references

Cochrane Oral Health Blog – What are the most accurate tests for screening for cancer of the mouth (oral cancer) and conditions that may lead to oral cancer?

UK National Screening Committee – Recommendations on Oral Cancer Screening Nov. 2020

Dental Elf 23rd July 2021

Oral cancer – adjunctive diagnostic tests

Dental Elf – 25th Nov 2013

Oral examination to detect potentially malignant disorders and mouth cancer


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