Data sources The Cochrane Oral Health Group's Trials Register, and Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, PsycINFO, Current Controlled Trials, ClinicalTrials.gov, Web of Science and Dissertations and Theses via Proquest databases were searched. A number of relevant journals, (Acta Odontologica Scandinavica, ASDC Journal of Dentistry for Children, British Dental Journal, Caries Research, Community Dental Health, Community Dentistry and Oral Epidemiology, Journal of the American Dental Association, Journal of Dental Research, Journal of Public Health Dentistry, Swedish Dental Journal, International Journal of Paediatric Dentistry) not already searched as part of the Cochrane Journal Handsearching Programme were handsearched. There were no restrictions regarding language or date of publication. Study selection Randomised controlled trials (RCTs) where randomisation occured at the level of the group (cluster by school and/or class) or individual children were included. Included studies had to include behavioural interventions addressing both toothbrushing and consumption of cariogenic foods or drinks and have a primary school as a focus for delivery of the intervention. Data extraction and synthesis Two pairs of review authors independently extracted data related to methods, participants, intervention design including behaviour change techniques (BCTs) utilised, outcome measures and risk of bias. A qualitative synthesis was conducted. Results Four studies involving a total of 2302 children were included. One study was at unclear risk of bias and three were at high risk of bias. The studies were heterogeneous in both intervention and outcome measures and also suffered from poor reporting. Only one included study reported caries development as an outcome. This small study at unclear risk of bias showed a prevented fraction of 0.65 (95% confidence interval (CI) 0.12 to 1.18) in the intervention group. However, as this is based on a single study, this finding should be interpreted with caution. All three studies that reported plaque outcomes found statistically significant reduction in plaque in the intervention groups, but due to differences in plaque reporting between studies these could not be combined. Two of these studies included an active home component where parents were given tasks relating to the school oral health programme, (games and homework) to complete with their children. Secondary outcome measures from one study reported that the intervention had a positive impact upon children's oral health knowledge. Conclusions Currently, there is insufficient evidence for the efficacy of primary school-based behavioural interventions for reducing caries. There is limited evidence for the effectiveness of these interventions on plaque outcomes and on children's oral health knowledge acquisition. None of the included interventions were reported as being based on or derived from behavioural theory. There is a need for further high quality research to utilise theory in the design and evaluation of interventions for changing oral health related behaviours in children and their parents.

Data sources Medline, Embase, CINAHL, LILACS, Cochrane Database of Systematic Reviews, OpenGrey (System for Information on Grey Literature in Europe [SIGLE]-based), Scirus, Science.gov, Cost-Effective Analysis (CEA) Registry, European Network of Health Economics Evaluation Databases (EURON-HEED), ClinicalTrials.gov and Health Services Research Projects in Progress (HSRProj) databases. They also contacted 20 separate organisations. Study selection All study designs were considered with no limits on dates, age of study, language or country. Government reports, peer-reviewed publications, dissertations and theses were included. Editorials, opinion pieces, educational pieces, narrative reviews, abstracts without full-text availability and raw data such as those from national oral health surveys were excluded. Study quality and risk of bias was assessed. Data extraction and synthesis Data extraction was conducted independently, and meta-analysis was planned for the data, but only a qualitative synthesis could be conducted. Results Eighteen observational studies were included, 13 were considered to be at high risk of bias, five at moderate risk and one at low risk. They were conducted in Australia, Canada, Hong Kong, New Zealand and the United States. All the studies were related to dental caries with only studies involving dental nurses and therapists meeting the inclusion criteria. No studies regarding cost effectiveness, irreversible diagnostic procedures or diseases other than caries were in included. Conclusions The authors concluded that the quality of the evidence was poor. They found that in select groups in which participants received irreversible dental treatment from teams that included midlevel providers, caries increment, caries severity or both decreased across time; however, there was no difference in caries increment, caries severity or both compared with those in populations in which dentists provided all irreversible treatment. In select groups in which participants had received irreversible dental treatment from teams that included midlevel providers, there was a decrease in untreated caries across time and a decrease in untreated caries compared with that in populations in which dentists provided all treatment.

Data sources Medline, Embase, Lilacs. Study selection Published and unpublished observational population-based studies presenting information on the prevalence, incidence, case fatality and cause-specific mortality related to untreated caries, severe periodontitis and severe tooth loss between January 1980 and December 2010. There were no language restrictions. Study quality was assessed using the STROBE checklist ( http://www.strobe-statement.org/ ). Data extraction and synthesis Prevalence estimates were calculated on the database for all age-gender-country-year groups using a specifically developed Bayesian meta-regression tool. Disability-adjusted life-years (DALYs) and years lived with disability (YLDs) metrics were used to quantify the disease burden. Disability weights were calculated based on population-based surveys in five countries (USA, Peru, Tanzania, Bangladesh and Indonesia) and an open Internet survey. Uncertainties in estimates were examined using Monte Carlo simulation techniques with uncertainty levels presented as the 2.5th and 97.5th centiles, which can be interpreted as a 95% UI. Results Oral diseases remain highly prevalent in 2010 affecting 3.9 billion people. Untreated caries in permanent teeth was the most prevalent condition evaluated for the entire GBD (Global Burden of Disease) 2010 Study with a global prevalence of 35% for all ages combined. Severe periodontitis and untreated caries in deciduous teeth were the 6th and 10th most prevalent conditions, affecting, respectively, 11% and 9% of the global population. Oral conditions combined accounted for 15 million DALYs globally (1.9% of all YLDs and 0.6% of all DALYs), implying an average health loss of 224 years per 100,000 people. DALYs due to oral conditions increased 20.8% between 1990 and 2010, mainly due to population growth and aging. While DALYs due to severe periodontitis and untreated caries increased, those due to severe tooth loss decreased. Conclusions The findings highlight the challenge in responding to the diversity of urgent oral health needs world-wide, particularly in developing communities.

Data sources The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, LILACS and BBO, ProQuest Dissertations and Theses, Web of Science Conference Proceedings and ClinicalTrials.gov databases were searched. Reference lists of identified articles were also scanned for relevant papers. Study authors were contacted for additional information. Study selection Randomised or quasi-randomised controlled trials using or indicating blind outcome assessment that compared fluoride varnish to placebo or no treatment for at least one year were included. Risk of bias assessment was undertaken. Data extraction and synthesis Study assessment and data extraction was carried out independently by at least two reviewers. The primary measure of effect was the prevented fraction, that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. The caries increments nearest to three years were used from each included study. Random-effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random-effects meta-regression analyses. Adverse effects information was collected from the included trials. Results Twenty-two trials (12,455 participants) were included. Thirteen trials were included in the permanent tooth surfaces meta-analysis, the pooled D(M)FS prevented fraction estimate comparing fluoride varnish with placebo or no treatment was 43% (95% confidence interval (CI) 30% to 57%; P < 0.0001). There was substantial heterogeneity, confirmed statistically (P < 0.0001; I 2 = 75%), however this body of evidence was assessed as of moderate quality. Ten trials contributed to the meta-analysis of primary teeth, the pooled d(e/m)fs prevented fraction estimate was 37% (95% CI 24% to 51%; P < 0.0001), there was some heterogeneity (P = 0.009; I 2 = 59%) this evidence was assessed as of moderate quality. No significant associations in either dentitions were found with baseline caries severity, background exposure to fluorides, application features such as prior prophylaxis, concentration of fluoride or frequency of application. There was little information concerning possible adverse effects or acceptability of treatment. Conclusions The conclusions of this updated review remain the same as when it was first published. The review suggests a substantial caries inhibiting effect of fluoride varnish in both permanent and primary teeth; however the quality of the evidence was assessed as moderate, as it included mainly high risk of bias studies, with considerable heterogeneity.

The Evidence Live Conference organised by the BMJ Group and the Oxford Centre for Evidence-based Medicine this year took place in Oxford.

Data sources The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, LILACS, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wan Fang Database, OpenGrey and ClinicalTrials.gov databases were searched. Reference lists of identified articles were also scanned for relevant papers. There were no language restrictions. Study selection Randomised controlled trials (RCTs) evaluating OHC in the form of mouthwashes, swabs, toothbrushing or in combination in critically ill patients receiving mechanical ventilation were included. Data extraction and synthesis Data extraction was carried out independently by two reviewers. Study authors were contracted for additional information. Random-effects meta-analyses were performed where data could be pooled. Results Thirty-five RCTs (5374 participants) were included. Five trials (14%) were assessed at low risk of bias, 17 studies (49%) were at high risk of bias and 13 studies (37%) were assessed at unclear risk of bias in at least one domain. There were four main comparisons; chlorhexidine (CHX mouthrinse or gel) versus placebo/usual care, toothbrushing versus no toothbrushing, powered versus manual toothbrushing and comparisons of oral care solutions. Seventeen RCTs (2402 participants, two at high, 11 at unclear and four at low risk of bias) provide moderate quality evidence that CHX mouthrinse or gel, as part of OHC, compared to placebo or usual care is associated with a reduction in VAP (OR 0.60, 95% confidence intervals (CI) 0.47 to 0.77, P < 0.001, I 2 = 21%) A number needed to treat (NNT) of 15 (95% CI 10 to 34). There is no evidence of a difference between CHX and placebo/usual care in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There was insufficient evidence to determine whether there is a difference between CHX and placebo/usual care in the outcomes of duration of use of systemic antibiotics, oral health indices, microbiological cultures, caregivers' preferences or cost. Only three studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups. Three trials in children found no evidence of a difference between OHC with CHX and placebo, and there was insufficient evidence to determine the effect of other outcomes. Four RCTs (828 participants, low quality evidence) compared to OHC without toothbrushing (± CHX), and for the outcome of VAP no evidence of a difference was found (OR 0.69, 95% CI 0.36 to 1.29, P = 0.24, I 2 = 64%). There was insufficient evidence to determine the effect of other outcomes. Only one trial compared use of a powered toothbrush with a manual toothbrush, providing insufficient evidence to determine the effect on any of the outcomes of this review. A range of other oral care solutions were compared. There is some weak evidence that povidone iodine mouthrinse is more effective than saline in reducing VAP (OR 0.35, 95% CI 0.19 to 0.65, P = 0.0009, I 2 = 53%) (two studies, 206 participants, high risk of bias). Due to the variation in comparisons and outcomes among the trials in this group there is insufficient evidence concerning the effects of other oral care solutions on the outcomes of this review. Conclusions Effective OHC is important for ventilated patients in intensive care. OHC that includes either chlorhexidine mouthwash or gel is associated with a 40% reduction in the odds of developing ventilator-associated pneumonia in critically ill adults. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both CHX and toothbrushing is different from OHC with CHX alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP.

Data sources PubMed, CINAHL, Cochrane Library, National Guidelines Clearinghouse, Web of Science and Google Scholar databases were searched. Study selection Experimental and non-experimental English language studies in adults in hospitalised and non-hospitalised patients were included. Data extraction and synthesis A qualitative summary of the included studies was presented. Results Seven experimental and three descriptive studies were included. All of the studies examined toothbrush contamination and found significant bacterial retention and survival on toothbrushes after use. A number of decontamination techniques were studied and a range of active agents reduced bacterial load. Closed storage containers generally increased bacterial load or survival times. Toothbrush design was also seen to have varying impact on bacterial load. Conclusions The selected studies found that toothbrushes of healthy and oral diseased adults become contaminated with pathogenic bacteria from dental plaque, design, environment or a combination of factors. There are no studies that specifically examine toothbrush contamination and the role of environmental factors, toothbrush contamination, and vulnerable populations in the hospital setting (eg critically ill adults) and toothbrush use in nursing clinical practice.

Data sources Medline, The Cochrane Central Register of Controlled Trials (CENTRAL) and Embase databases were searched. Study selection Screening and selection of studies was conducted independently by two authors, with randomised controlled trials (RCTs) or controlled clinical trials (CCTs) conducted in adults 18 years or older being included. Studies used the outcome measures of volatile sulphur compounds (VSCs), organoleptic measurement (OM) and tongue coating (TC). Studies with a duration of greater than one day were included. Selection was restricted to English language papers. Data extraction and synthesis Study quality was assessed by two authors with studies being separated into short- term (< 3 weeks) and longer-term study period groups (≥3 weeks). Meta-analysis was not conducted because of heterogeneity in the study designs, products used, outcome measures and data presentation. Results Twelve RCTs were included (six cross-over studies and six parallel design). The short-term studies ranged from four days to two weeks and the long-term studies from three to four weeks. The risk of bias was assessed as high for two studies, moderate for three and low for seven. Nearly all mouthwashes with active ingredients had beneficial effects in reducing oral malodour in both short- and longer-term studies. Conclusions The most compelling evidence was provided for chlorhexidine mouthwashes, and those that contained a combination of cetyl pyridinum chloride and zinc provided the best evidence profile on oral malodour. Little data with respect to tongue coating were available, and none of the studies showed a beneficial effect for this parameter.

A new mobile app to facilitate drug prescribing in primary care has been launched by the Scottish Dental Clinical Effectiveness Programme (SDCEP). Dental Prescribing is available to purchase from the App StoreSM for use on iPhone®, iPad® and iPod touch®.

Data sources The BBO (Bibliografia Brasileira de Odontologia), Biomed Central, Cochrane Library, Directory of Open Access Journals, LILACS, Open-J-Gate, OpenSIGLE, PubMed, Sabinet and Science-Direct databases were searched. Study selection Articles were selected for review from the search results on the basis of their compliance with the broad inclusion criteria: relevant to the review question; and prospective two-arm (or more) clinical study. The primary outcome measure was the incidence of AO reported at the patient level. Data extraction and synthesis Two reviewers (VY and SM) independently extracted data and assessed the quality of the accepted articles. Individual dichotomous datasets for the control and test group were extracted from each article. Where possible, missing data were calculated from information given in the text or tables. In addition, authors were contacted in order to obtain missing information. Datasets were assessed for their clinical and methodological heterogeneity following Cochrane guidelines. Meta-analysis was conducted with homogeneous datasets. Publication bias was assessed by use of a funnel plot and Egger's regression. Results Ten randomised trials were included; almost all involved the removal of third molars. Only two of six identified application protocols (single application of chlorhexidine 0.2% gel or multiple application of 0.12% rinse versus placebo) were found to significantly decrease the incidence of AO. Conclusions Within the limitations of this review, only two of six identified application protocols were found to significantly decrease the incidence of AO. The evidence for both protocols is weak and may be challenged on the grounds of high risk of selection, detection/performance and attrition bias. This systematic review could not identify sufficient evidence supporting the use of chlorhexidine for the prevention of AO. Chlorhexidine seems not to cause any significantly higher adverse reactions than placebo. Future high-quality randomised control trials are needed to provide conclusive evidence on this topic.

Data sources PubMed, Medline, Embase, CINAHL via EBSCO and Cochrane library databases were searched. Study selection Randomised controlled trials that investigated the protective effects of honey in head and neck cancer patients undergoing radiation therapy that used either the Radiation Therapy Oncology Group (RTOG) or World Health Organisation (WHO) criteria for evaluating the severity of the radiation mucositis were included. Risk of bias was assessed using the Cochrane methodology. Data extraction and synthesis A meta-analysis was conducted using a fixed-effects model. Heterogeneity was assessed using the I 2 statistic. Results Three randomised trials involving a total of 120 patients were included. The overall relative risk of developing mucositis was almost 80% lower (risk ratio, 0.19; 95% CI, 0.098 – 0.371) in the honey treatment group than in the control group. Conclusions Despite promising results, the weaknesses of the individual studies highlight the need for further, more rigorous, randomised controlled trials. Future studies need to address the weakness of available studies by adequately describing the method of randomisation and allocation concealment.

Data sources Electronic (PubMed and Medline) and hand searching of three dental public health journals, Community Dental Health, Community Dentistry and Oral Epidemiology and the Journal of Public Health Dentistry 1993 - 2008. Study selection Studies defined as controlled experiments using a random method to assign study units were included: papers reporting secondary analysis, pilot studies and those that provided brief methodological descriptions were excluded. Data extraction and synthesis Each article included in the study was assessed and scored independently by two observers, with any discrepancies being resolved by discussion Articles were assessed using the CONSORT criteria. Results 119 RCTs were initially identified (85 electronically and 33 from hand searching) and of these 48 were assessed. Of the 56 CONSORT criteria there were on average 27 (SD 6.9) present. The average number of criteria increased over the period. Conclusions There were inadequacies in the reporting of trials in dental public health journals. The quality of the reporting could be improved if the CONSORT statement were followed more closely.

Data sources British Nursing Index, CINAHL, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects), EMBASE, Medline, PsycINFO and the reference lists of eligible papers were searched. Study selection Studies that focused on practitioners with special interests (PwSIs) or roles clearly created/defined to be practising with special interests, detailing innovative ways of working with a special interest with evidence of formal evaluation of changing role of location of service from systematic reviews or interventions were included. Surveys of views on changing skill-mix or location of services, studies that did not concern dental or medical professionals, dental care or nursing professionals were excluded. Only studies in English and with a UK focus were included. Data extraction and synthesis All titles and abstracts identified were screened for relevance. Two authors assessed quality and extracted data, queries were reviewed by a third author and a narrative synthesis was presented. Results Twenty-six papers met the criteria with a strong bias towards the medical literature. Five categories emerged:(i) specialist outreach; (ii) general practitioners with a special interest; (iii) nurse practitioners with a special interest; (iv) dental care professionals; (v) out-of-hospital services. Evidence showed specialist outreach clinics to be effective in relation to access and patient satisfaction with some having a higher quality of care but higher cost. However there may be cost-benefits associated with this care, particularly when part of a multifaceted intervention. There is controversy and a limited evidence as to whether the services provided by medical PwSIs are effective, and whether the benefits outweigh the risk and the cost. From the evidence obtained through early innovation, it appears that these services can increase access and are more satisfying for patients, and that these roles have the potential to bring more work satisfaction to the practitioners. Overall, the findings do support the view that moving specialist care into the primary care setting via appropriately trained nurse practitioners is an effective use of resources, but with the caveat that nurse practitioners in primary care are not necessarily cost-effective. There is evidence that professionals complementary to dentistry (PCDs) are able to diagnose a range of conditions and, with appropriate training, complete a wide range of dental procedures as well as dentists, but much of the evidence for other aspects of substitution was of lower quality, weak or insufficient. Conclusions There was limited evidence of the cost-effectiveness and health outcomes associated with changes in setting and skill-mix. However, there was evidence of improved access, patient and professional satisfaction. There is an overwhelming need for well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce.

In this issue we look at a number of articles that address the topic of oral cancer screening. This is a subject that I have written about in the past.1 These three articles, an evidence-based clinical recommendation,2 a Cochrane review3 and a clinical trial4 in my view reinforce my perspective, or bias if you wish, that there is not sufficient evidence to support calls for screening programmes for oral cancer, although there is some weak evidence that it may be of some benefit in regions with a high incidence of the disease. It is however not in these areas where the largest push for screening programmes is seen. Support for screening programmes in primary care is often promoted by those with interests in adjunctive technologies like toluidine blue, brush biopsy or fluorescence imaging. Yet neither the Cochrane review nor the ADA clinical recommendations found robust evidence to support them. Those with an interest in this area might like to take a look at a page of the website of the Scope Group (www.thescopegroup.com/dental/case_history.htm), a UK dental marketing company that handles one of these adjunctive products. That said, we are all aware that oral cancer is an important public and oral health issue and the dental team have an important role in its early detection and management. This role is very well laid out in a recently published BDA Occasional Paper.4 This paper is an excellent resource that provides a brief clear overview of oral cancer in the UK and clearly outlines what dentists and the dental team should do both to prevent oral cancer and detect early lesions. The focus of the paper is to move practitioners away from screening towards case detection and to encourage them to improve the quality of their oral mucosal examination. It also highlights the first priority, that of primary prevention. As dental practitioners we see our patients regularly and have the opportunity to both initiate discussions about smoking, alcohol use and diet and provide advice about smoking cessation, reducing alcohol consumption and good diet. The BDA paper provides key messages and tips and links to a wide range of other helpful resources. Another important role for the dental practitioner is to help raise awareness of oral cancer as a condition, for despite the fact that here in the UK there has been an annual mouth cancer awareness campaign for several years, it is evident from one of the other papers reviewed in this issue6 that there are still gaps in the public's understanding and awareness of oral cancer. So for me the role of the dental team is clear, we must:

Scope and purpose To address the benefits and limitations of oral cancer screening and the use of adjunctive screening aids to visualise and detect potentially malignant and malignant oral lesions. Squamous cell carcinomas of the lips and cancers of the oropharynx (including the posterior one-third of the base of the tongue and the tonsils were excluded. Methodology A specially convened expert panel evaluated the available evidence which was derived from a systematic search of Medline and the Cochrane Library. Further details about the search are available in a supplement to the published article available on the Journal of the America Dental Association's website ( http://jada.ada.org/cgi/content/full/141/5/509 ). Qualitative synthesis of the data was performed by the panel. Where consensus could not be reached majority voting was employed. Recommendations were reviewed by internal and external scientific experts and organisations. After review recommendations were revised where appropriate and the ADA Council on Scientific Affairs approved the final clinical recommendations. Review and updating No information provided in article. Recommendations The key recommendations were all classified as level D being based on grade IV evidence or extrapolated from grade I, II or III evidence using a system based on Shekelle et al. 1 The main recommendations can be summarised as: 1) Clinicians should 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. 2) For seemingly innocuous lesions, clinicians should follow up in seven to 14 days to confirm persistence after removing any possible cause to reduce the potential for false-positive screening results. 3) For lesions that raise suspicion of cancer or for lesions that persist after removal of a possible cause, clinicians should communicate the potential benefits and risks of early diagnosis. Considerations include the following: a) that even suspicious lesions identified during the course of a routine visual and tactile examination may represent false positives; b) 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; c) that a malignancy or non-malignancy can be confirmed only via microscopic examination that requires a surgical biopsy; d) that a decision to pursue a biopsy to confirm the presence or absence of malignancy should be made in the context of informed consent. 4) Although transepithelial cytology has validity in identifying disaggregated dysplastic cells, the panel suggests surgical biopsy for definitive diagnosis Research recommendations In all, 15 separate research recommendations were made ranging from determining the prevalence of potentially malignant oral mucosal lesions in the United States to whether the use of adjunctive devices improves patient education and adherence to follow-up care.

A randomised controlled trial.28,167 individuals aged 15 years or older who were invited participate in a screening programme, 17,890 who lacked oral habits such as cigarette smoking or chewing betel quid were excluded leaving 10,277 eligible individuals. Of these, 2,302 refused to participate leaving a sample of 7,975 for randomisation. The test group gargled with toluidine blue solution while the control group was given a placebo dye of the same colour. Each participant was visually examined by one of six dentists with additional training. The presence of any visible lesion in the oral cavity (e.g. abnormal mucosal lesions related to OPMLs and other suspected lesions such as lichen planus, oral ulcer, hyperkeratosis, candidiasis, etc) was recorded as screen-positive. The screen-positive participants to a specialist were referred to a specialist for a definite clinical diagnosis within 10 to 14 days, to reduce false-positivity, and biopsies were arranged if oral lesions were present. The occurrence of oral cancer, survival status, and causes of death of the studied participants for the entire cohort was obtained from the National Cancer Registry and the National Household Registry until the end of 2004.The number of oral lesions, premalignant or not.In the test group 389 (9.5%) individuals had a positive screen compared with 322 (8.3%) in the control group. Two oral cancers were identified out of those with a positive screen presenting (n=320) for the referral examination from the test group with three oral cancers out of the 293 in those who complied in the control group. There were three oral cancers ascertained by the end of the follow-up among the screen-negatives in each arm (test and control) by the end of the followup period. The numbers of OPMLs in each arm of the study are shown in Table 1.We demonstrated that using toluidine blue as an adjunctive tool for visual screening can detect significantly more oral submucous fibrosis and slightly more leukoplakia among high-risk individuals with habits of cigarette smoking or betel quid chewing as compared with visual screening alone.