Evaluation of Potentially Malignant Disorders of Oral Cavity: ADA Clinical Practice Guideline

An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review. It formulated clinical recommendations to inform primary care clinicians about the potential use of adjuncts as triage tools for evaluating lesions, including potentially malignant disorders (PMDs), in the oral cavity.

This is an update of the ADA's 2010 recommendations on the early diagnosis of PMDs and oral squamous cell carcinoma. The authors searched the literature in MEDLINE and Embase via Ovid and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials and diagnostic test accuracy studies. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and to move from the evidence to the decisions.

Results:

The panel formulated 1 good practice statement and 6 clinical recommendations that concluded that no available adjuncts demonstrated sufficient diagnostic test accuracy to support their routine use as triage tools during the evaluation of lesions in the oral cavity. For patients seeking care for suspicious lesions, immediate performance of a biopsy or referral to a specialist remains the single most important recommendation for clinical practice. In exceptional cases, when patients decline a biopsy or live in rural areas with limited access to care, the panel suggested that cytologic testing may be used to initiate the diagnostic process until a biopsy can be performed (conditional recommendation, low-quality evidence).

Recommendations:

Recommendation 1: The panel suggests that for adult patients with a clinically evident oral mucosal lesion with an unknown clinical diagnosis considered to be seemingly innocuous or nonsuspicious of malignancy, or other symptoms, clinicians should follow up periodically with the patient to determine the need for further evaluation. Suppose the lesion has not resolved and the clinical diagnosis of a potentially malignant disorder cannot be ruled out. In that case, clinicians should perform a biopsy of the lesion or refer the patient to a specialist.

Recommendation 2: The panel suggests that for adult patients with a clinically evident oral mucosal lesion considered to be suspicious of a potentially malignant or malignant disorder, or other symptoms, clinicians should perform a biopsy of the lesion or provide an immediate referral to a specialist.

Recommendation 3: The panel does not recommend cytologic adjuncts to evaluate potentially malignant disorders among adult patients with clinically evident, seemingly innocuous, or suspicious lesions. Should a patient decline the clinician's recommendation for performing a biopsy of the lesion or referral to a specialist, the clinician can use a cytologic adjunct to provide additional lesion assessment.

Recommendation 4: The panel does not recommend autofluorescence, tissue reflectance, or vital staining adjuncts to evaluate potentially malignant disorders among adult patients with clinically evident, seemingly innocuous, or suspicious lesions. A positive or atypical cytologic test result reinforces the need for a biopsy or referral. A negative cytologic test result indicates the need for periodic follow-up of the patient. If the clinician detects persistence or progression of the lesion, immediately performing a biopsy of the lesion or referral to a specialist is indicated.

Recommendation 5: The panel suggests that for adult patients with no clinically evident lesions or symptoms, no further action is necessary at that time.

Recommendation 6: The panel does not recommend commercially available salivary adjuncts to evaluate potentially malignant disorders among adult patients with or without clinically evident, seemingly innocuous, or suspicious lesions, and their use should be considered only in the context of research.

The authors urge clinicians to remain alert and take diligent action when identifying a PMD. The authors emphasize the need for counselling because patients may delay diagnosis because of anxiety and denial.

Reference:

Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity: A report of the American Dental Association by Mark W. Lingen, et al. published in the American Dental Association

DOI: https://doi.org/10.1016/j.adaj.2017.07.032