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Practice Guideline
. 2026 Jun;157(6):576-587.
doi: 10.1016/j.adaj.2026.01.014. Epub 2026 Apr 6.

Living evidence-informed guideline on the early detection of oral squamous cell carcinoma and potentially malignant disorders: Vital staining adjuncts to determine the need for biopsy, Version 2026 1.0

Carolina Martins-Pfeifer  1 , Olivia Urquhart  2 , Francisca Verdugo-Paiva  2 , Ankita Shashikant Bhosale  2 , Alonso Carrasco-Labra  3 , Julia Pimentel  2 , Natalie Sadek  4 , A Ross Kerr  5 , Marco Magalhaes  6 , Carol Anne Murdoch-Kinch  7 , JoAnn Gurenlian  8 , Nishant Agrawal  9 , Anil K Chaturvedi  10 , Eva Grayzel  11 , Alexander T Pearson  12 , James C Melville  13 , Anita S H Patel  14 , Alessandro Villa  15 , Michael Glick  2 , Mark W Lingen  16
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Free article
Practice Guideline

Living evidence-informed guideline on the early detection of oral squamous cell carcinoma and potentially malignant disorders: Vital staining adjuncts to determine the need for biopsy, Version 2026 1.0

Carolina Martins-Pfeifer et al. J Am Dent Assoc. 2026 Jun.
Free article

Abstract

Background: Early detection of oral potentially malignant disorders (OPMDs) and oral cavity cancer can improve patient prognosis. In this guideline, the authors address the use of vital staining, specifically toluidine blue, as an adjunct to screen adults without mucosal abnormalities and to determine the need for biopsy among adults with mucosal abnormalities in the oral cavity.

Types of studies reviewed: The authors conducted systematic searches to identify evidence on the benefits and harms of using vital staining as an adjunct as well as patient and clinician values and preferences regarding the use of this adjunct. The guideline panel used the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision framework to formulate recommendations. As part of the framework, the panel also considered the resources required, equity, acceptability, and feasibility when formulating recommendations.

Results: The panel formulated 2 recommendations and 2 good practice statements. For adults with and without mucosal abnormalities, the panel recommend against the use of vital staining as an adjunct (conditional recommendation, very low certainty). The good practice statements encourage clinicians to perform a clinical oral examination in all adult patients.

Conclusions and practical implications: Biopsy remains the first choice for obtaining a definitive diagnosis of an OPMD and oral squamous cell carcinoma. Clinical oral examination should be performed in all asymptomatic adults with no clinically evident mucosal abnormality. When implementing or adapting these recommendations, local contexts should be taken into account to ensure equitable access to early detection.

Keywords: Oral cancer; biopsy; diagnosis; early detection; living guideline; potentially malignant disorder; toluidine blue.

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Conflict of interest statement

Disclosures Dr. Melville volunteers as a clinical advisory board member for Proteocyte AI, a privately owned medical technology company. Dr. Agrawal has equity ownership in OrisDX, a salivary diagnostics start-up, and has a submitted patent related to head and neck cancer genetics and salivary biomarkers. Dr. Pearson is a scientific advisory board member for Thermo Fisher and Daiichi Sankyo and received travel funding from Caris and research funding from Abbvie and Merck. None of the other authors reported any disclosures.

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