Oral Cancer - Oral Screening
Why Screen?

The stage that Oral Squamous Cell Carcinoma (OSCC) is
diagnosed has a bearing on the outcome of
OSCC; oro-
pharyngeal cancers
have relatively ‘silent’ symptoms which
may not be present during the early stages of the disease,
which is possibly why the stage of disease at diagnosis
has not altered in the last 40 years despite public

For this reason, there is an interest in the early
identification of
OSCC yet the case for formal screening
programmes does not meet the criteria established by the
UK Screening Committee.

The Cochrane review on oral screening for OSCC found
that overall there is not enough evidence to decide whether
screening by visual inspection reduces the death rate for
oral cancer and there is no evidence for other screening

GDP can expect to see at least a couple of mouth
cancer lesions during their practising lifetime.  Obviously,
this is an average statistic affected by geographical
location and social class of clientèle, much like the
statistics for
caries (tooth decay).

Nevertheless, to miss such a diagnosis could have a
significant effect upon a patient’s health, quality and
longevity of life and, of course, might leave the clinician
open to criticism by the patient, and possibly give rise to
medico-legal concerns.

One of the main problems with oral screening is limited
accessibility to the dental office

High risk groups are those less likely to have access to an
NHS dentist and therefore less likely to have regular dental

These patients, many of whom are elderly, are less likely
to schedule regular visits to the dentist due to financial
constraints, a lack of adequate facilities or indifference
towards their oral health.

Oral Cancer Screening

For oral cancer, where large numbers of patients are
already seeing a dentist, an '
opportunistic screening'
approach is generally advocated.

Opportunistic screening' is less systematic but very much
more cost-effective than
population screening. If an
opportunistic screening strategy is to be successful, all
dentists should carry out the necessary soft tissue
examination alongside hard tissue examinations.

Screening for oral cancer and pre-cancer becomes part of
the routine examination.  In practice, this will normally be at
the beginning of each new course of treatment.

ViziLite® is an oral cancer screening tool that may help the clinician more easily
visualise suspicious lesions.  It is
not a diagnostic tool.  

In the UK, it is sold by
Panadent.  Checking their website, there seems to be a
patchy take up over England; seemingly most of the
GDP practices are based in
Essex.  Possibly not to be sensationalist, not many of practices using this system,
advertise their
oral cancer screening facility.

Kit contents:

Chemi-luminescent device
•        30 ml acetic acid
•        Light stick holder / retractor
Last Updated 22nd November 2018
Useful Websites:

The Oral Cancer Foundation

The Mouth Cancer Foundation

Homestead Schools, Inc (Dental)

National Institute for Health Research (NIHR)

CancerHelp UK

International Agency for Research on Cancer / World Health Organisation



Oral Cancer LDV

Oral Cancer Recognition Toolkit

Useful Articles:

BDA Occasional Paper 2000.  Opportunistic Oral Cancer Screening.

Department of Public Health and Epidemiology, University of Birmingham 2000.  
The clinical effectiveness of toluidine blue dye as an adjunct to oral cancer
screening in general dental practice.  A West Midlands Development and
Evaluation Service Report.

BDJ 2003.  Oral Cancer Prevention & Detection in Primary Healthcare.

Oral Oncology 2003.  The effectiveness of community-based visual screening and
utility of adjunctive diagnostic aids in the early detection of oral cancer

Agency for Healthcare Research and Quality 2004.  Screening for Oral Cancer. A
Brief Evidence Update for the U.S. Preventive Services Task Force.

J Med Screen 2006.  Does the ‘Inverse Screening Law’ apply to Oral Cancer
Screening & Regular Dental Check-ups?

Oral Oncology 2007.  Review.  Critical Evaluation of Diagnostic Aids for the
Detection of Oral Cancer.

Am J Dent 2008.  Review Article.  Oral Cancer - Current & Future Diagnostic

JADA 2008.  Adjunctive Techniques for Oral Cancer Examination & Lesion
Diagnosis.  A Systematic Review of the Literature.

JADA 2008.  Oral Rinses may help detect HPV-positive Head & Neck Cancers

Bulletin of the World Health Organization 2009.  Cost-effectiveness of Oral Cancer
Screening - Results from a Cluster Randomized Controlled Trial in India.

Family Practice 2009.  Conducting Oral Examinations for Cancer in General
Practice - What are the barriers?

Evidence-Based Dentistry 2009.  Editorial.  Should we screen for Oral Cancer?

BDJ 2009.  A qualitative study examining the experience of primary care dentists
in the detection & management of potentially malignant lesions. 1. Factors
influencing detection

J Dent Res 2010.  A community-based RCT for oral cancer screening with
toluidine blue.

JADA 2010.  Evidence-based clinical recommendations regarding screening for
oral squamous cell carcinomas.

JADA 2010.  For The Dental Patient...Detecting Oral Cancer Early

DHHS, NIH & NIDCR.  Detecting Oral Cancer - A guide for health care

Screening.nhs.uk 2010.  Evaluation of Screening for Oral Cancer against NSC

Evidence-Based Dentistry 2010.  Clinical Recommendations for Oral Cancer

Evidence Based Dentistry 2010.  Editorial.  Seek, don’t screen for Oral Cancer.

Evidence-Based Dentistry 2010.  Does Toluidine Blue Detect More Oral Cancer

Cochrane Database of Systematic Reviews 2010.  Screening programmes for the
early detection and prevention of oral cancer.

BDJ 2010.  The Reality of Identifying Early Oral Cancer in the General Dental

JADA 2010.  Detecting Oral Cancer Early

Vital 2011.  Making oral cancer screening a routine part of your patient care.   
Part 1

Vital 2011.  Making oral cancer screening a routine part of your patient care.   
Part 2

BDA 2011.  Early Detection of Oral Cancer.  A Management Strategy

BJOMS 2011.  Management of Oral Carcinoma.  Benefits of early Pre-Cancerous

JADA 2011.  Rise in Oral Cancer Linked to HPV, Study Shows

JADA 2011.  The Connection between HPV & Oroparyngeal Squamous Cell
Carcinomas in the US.  Implications for Dentistry

BDJ 2012.  Microscope Created For Early Oral Cancer Diagnosis

BDJ 2016.  Letters to the Editor.  Mouth Cancer.  Extending the RULE

BDJ 2018.    Screening for Mouth Cancer - The Pros & Cons of a National
ViziLite® Procedure.  Steps:

1.        Patient rinses with 1% acetic acid for 1 minute
Chemi-luminescent device activated & placed in ‘light stick’ holder.
3.        Dim room lighting
4.        Visually inspect oral cavity using device
5.        Record any findings and refer the patient if necessary

How ViziLite® Works

Normal epithelium (skin) absorbs the light and appears dark; abnormal tissue
reflects light and appears bright white.  Based upon the current suggested usage
for these devices, it is unclear what added benefit they would provide to the
practicing clinician.
Toluidine Blue

  • Meta-chromatic dye
  • Stains nuclear DNA
  • 1% aqueous solution followed by 1% acetic acid to de-colourise the oral lesion
  • ‘Abnormal’ tissue retains the blue dye

Tolonium chloride or toluidine blue, is a stain that like Vizilite, is used as a
screening device to help the clinician more easily visualise suspicious lesions.

toluidine blue appears to be good at detecting carcinomata but is positive
in only ~50% of lesions with
dysplasia.  In addition, it also frequently stains
common, benign conditions such as non-specific ulcers.

A systematic review concluded that there is no evidence that
toluidine blue is
effective as a screening test in a primary care setting.

The high rate of false positive stains and the low specificity in staining
likely outweigh the potential benefits of any additional cancers detected at this time.
OralCDx® Brush Biopsy

  • Computer-assisted analysis of oral brush biopsy
  • Evaluate benign appearing lesions
  • High accuracy
  • Does not replace scalpel biopsy

Henry Schein is the sole UK distributor for the oral
lesion brush biopsy
, Oral CDx, though checking their
website I can’t find it.

This allows
GDP’s to evaluate white or red lesions or
those lesions that have been identified using
.  It’s a step up from just screening.  The lesions are
brushed until they bleed and the collected cells are sent
to a lab for diagnosis.

It accurately detects pre-cancerous and cancerous

Recipient of “
Seal of Acceptance” of the American
Dental Association

That well known purveyor of fact, the Daily Mail, says
the test (& results) retail for £80.
All 3 layers (basal, intermediate and superficial layers) of epithelium are included /
OralCDx® results come back as negative (no cellular abnormalities), positive
(definitive cellular evidence of
epithelial dysplasia or carcinoma) or atypical
epithelial changes warranting further investigation).

Negative lesions require the same careful clinical follow-up as negative
histologically sampled lesions.  
Atypical and positive lesions require scalpel biopsy
and histology analysis.

A report is sent with results for any specimens with
atypical or positive findings.  
The report contains histological slides of the specimen and the
oral pathologist's


Often used inappropriately by the dentist.  For example, some use it on

Cells are seen out of context, which can result in misinterpretation.  For example, if
Brush Test is used to collect cells from a patient who has lichen planus and the
cells are spread out on a slide, they will be out of context and will be read as
Cancers 2012 - Vision Paper, that by 2012, a pilot scheme should have been held
in > 1 'spearhead PCT' to assess the effectiveness of
opportunistic visual oral
. This might include:

  • setting up of a dedicated Head & Neck Clinic every 3 - 4 months to which over-
    50's in high risk groups are invited

  • links to specialists in secondary care, for example, sending digital photos for
    advice prior to a decision to refer although there are concerns about the
    feasibility of producing good enough quality photos

  • posters in pharmacies offering mouth checks for ulcers

Also, action should have been taken with the manufacturers of products designed
for self-medication of
oral ulcers and related conditions for the medication carton to
carry a clear health warning about
oral cancer.  This will need to be managed
carefully to avoid large numbers of the “worried well” overwhelming services.

Finally, the
CRS opined that due to the problems of 'dental capacity' (which are
outside the scope of the
CRS to resolve), it may not be feasible to focus
opportunistic screening with dentists.  As a response to this perceived lack of
capacity, it was thought that
GP's and practice nurses (who often see high risk
groups for other issues such as high blood pressure) and
pharmacists (who are
often consulted about mouth ulcers) might be able to take up the slack.

Training issues and financial incentives would need to be considered as would the
advantages / disadvantages of screening being carried out by non-medical

Opportunistic Oral Cancer Screening

This was published by the British Dental Association in 2000.

This is quite comprehensive.  It covers:

  • Oral cancer screening - obligations and opportunities
  • Risk factors
  • Talking to patients about oral cancer
  • Administration
  • Examining the head, neck and soft tissue
  • Using tolonium chloride
  • Putting screening into practice

If you were considering offering this type of screening service, it is well worth
looking at.

It can be downloaded from here.

Oral Cancer Screening 'Visual Aids'

To augment the GDP’s visual check of the mouth, there are a number of 'aids' to
flag up suspicious areas.

These include:

  • ViziLite & MicroLux DL
  • Tolonium chloride (Toluidine Blue)
  • OralCDx® brush biopsy
  • Exfoliative cytology

Toluidine blue
has been used for a number of years.  ViziLite & OralCDx® are
quite new.  
Exfoliative cytology is included for the sake of completeness but I don’t
believe many
GDP practices do this.  This tends to be done in hospitals.

Most studies show that the various aids can help but when used for screening,
economically, it is too expensive for the number of lesions correctly picked up.

VELscope, OralCDx® and Toluidine Blue staining have high false positive rates
when they are used to screen routinely for
oral cancer.

It would be inefficient to allocate scarce healthcare resources to the routine use of
these devices for
oral cancer screening.

These devices may be beneficial in
opportunistic screening programmes or in
cancer referral clinics when the pre-test probability of oral cancer is likely to be
above 10%.

Further research is needed to determine at which pre-test probabilities, these
adjunctive diagnostic devices would be cost-beneficial for the screening of