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Clinical diagnosis of squamous cell carcinomas of the

oral mucosa is not difficult when the lesion is obvi-

ously invasive or when the patient experiences pain,

functional limitation, or regional lymphadenopathology.

Conversely, it is more difficult to diagnose dysplasias

and carcinomas mainly in potentially malignant epithe-

lial lesions (PMELs).

With the aim of improving the efficiency of these diag-

noses, techniques are being developed to complement

clinical examination and to facilitate the identification of

initial carcinomas. Several clinical studies have evalu-

ated the efficiency of in vivo staining with toluidine blue

in the detection of dysplasias and malignant lesions.

Although there is a consensus that this staining often

assists in the identification of these malignant lesions,

results have been diverse.1-17 This diversity of results is

probably due to variations in methodology, the popula-

tion studied, and the lesions analyzed. Warnakulasuriya

and Johnson16 emphasized that the majority of studies

analyzed few PMELs and large groups with clinically

suspected malignancy. In addition, in some of these

studies, biopsies of lesions that did not retain toluidine

blue were not performed.2,4,5,9 These factors may inter-

fere in the evaluation of staining, thus limiting the value

of results obtained. Thus, our objective in this study was

to determine the reliability of in vivo staining with tolu-

idine blue in the detection of oral epithelial dysplasia, in

situ carcinoma, and squamous cell carcinoma associated

with PMELs and superficial oral ulcerations suspicious

of malignancy.

PATIENTS AND METHODSFor this study 50 patients with PMELs and superfi-

cial oral ulcerations suggestive of malignancy were

selected from those treated at the Oral Medicine

Service, Faculty of Dentistry, Araraquara, So Paulo,

Brazil, from August 1993 to May 1995 (n = 1957). Not

included in this study were patients who refused to be

submitted to biopsy (n = 21), those who abandoned

treatment, or those who had clinically obvious invasive

carcinomas or lesions without risk or suspicion of

Reliability of toluidine blue application in the detection of oral

epithelial dysplasia and in situ and invasive squamous cell

carcinomas

Mirian Aparecida Onofre, DDS, PhD,a Maria Regina Sposto, DDS, PhD,b and Cludia Maria

Navarro, DDS, PhD,c So Paulo, BrazilSCHOOL OF DENISTRY ARARAQUARAUNESP

Objective. The objective of this study was to evaluate the reliability of in vivo staining with toluidine blue in the detection oforal epithelial dysplasia, in situ carcinoma, and invasive squamous cell carcinomas in potentially malignant epithelial lesions(PMELs) and superficial oral ulcerations suggesting malignancy.Study design. Fifty patients with PMELs and superficial oral ulcerations suggestive of malignancy were selected from thosetreated at the Oral Medicine Service, Faculty of Dentistry, Araraquara, Brazil. All lesions were submitted to staining with anaqueous solution of 1% toluidine blue, followed by biopsy and histologic analysis. The sensitivity, specificity, and positive andnegative predictive values were calculated.Results. Histologic diagnosis revealed that 14% of the lesions analyzed were in situ carcinoma and invasive squamous cell carci-nomas, 12% were epithelial dysplasias, 13% were keratosis, 40% were lichen planus, and 8% were other benign lesions. The sensi-tivity of the staining was 77%, the specificity 67%, and the positive and negative predictive values 43.5% and 88.9%, respectively.Conclusions. Staining with toluidine blue was demonstrated to be highly reliable in the detection of in situ carcinoma andinvasive squamous cell carcinoma, because false-negative results for the lesions did not occur. Toluidine blue staining is anadjunct to clinical judgment and not a substitute for either judgment or biopsy.(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:535-40)

Supported by grants CNPq no. 523164/96-3 and FAPESP no.

96/5927-8.

Presented at the 5th Biennial Congress of the European Association

of Oral Medicine, Gteborg, Sweden, Aug 24-26, 2000.aAssistant Professor, Oral Medicine Service, Department of

Diagnosis and Surgery, School of Dentistry AraraquaraUNESP, So

Paulo, Brazil.bAssociate Professor, Oral Medicine Service, Department of


Paulo, Brazil.cAssistant Professor, Oral Medicine Service, Department of


Paulo, Brazil.

Received for publication Jul 19, 2000; returned for revision Aug 23,

2000; accepted for publication Oct 30, 2000.

Copyright 2001 by Mosby, Inc.

1079-2104/2001/$35.00 + 0 7/13/112949

doi:10.1067/moe.2001.112949

535


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malignancy. Twenty-eight of the patients were men,

and 22 were women, 45 were white, 2 were black, 2

were mixed race, and 1 was Asian, with a mean age of

55.2 13.4 years. A clinical history of the lesion was

taken from each patient, and all were submitted to a

systematic oral examination. The criteria for clinical

diagnosis were (1) homogenous leukoplakia: apredominantly white, uniform, and flat lesion, not able

to be scraped, with a smooth, wrinkled, or corrugated

surface that may exhibit shallow cracks18,19; (2) nonho-

mogenous leukoplakia: a predominantly white or red

and white lesion with an irregular, nodular, or exophy-

tic surface18,19; (3) erythroplakia: a velvety red lesion

with imprecise borders that could not be diagnosed as

any other lesion18,19; (4) reticular lichen planus: a

predominantly white lesion with intertwining lines or

striae that confer a lacy or annular appearance19; (5)

erosive/ulcerated lichen planus: a predominantly red,

irregular erosion or ulceration associated with a retic-

ular form, especially in the peripheral region of thelesion and with pseudomembranes covering the ulcer-

ated areas19; (6) superficial ulcerations suspicious of

malignancy: localized, superficial lesions without inva-

sion or loss of mobility of neighboring chronic tissues

that do not heal after local treatment.

After clinical diagnosis the lesions were submitted to

topical application of an aqueous solution of 1% tolui-

dine blue, according to the technique shown in Table I.

The stain was prepared following the recommenda-

tions of Mashberg.8,10 In the lesions associated with

mechanical trauma, these sites were then eliminated,

and the staining was repeated after 14 days, with the

object of reducing the number of false-positive

results.8,10 The clinical diagnosis and staining results

were determined by 2 examiners, previously calibrated,

who were specialists in oral medicine, following the

recommendations made by Mashberg.7,10

The biopsy sites were selected on the basis of the

clinical appearance of the lesion and the staining result.

Areas retaining stain were biopsied. In sites where no

retention of stain occurred, clinical judgment directed

the biopsy. Erythematous, verrucous, depressed, ele-

vated, indurated, and diffuse margin areas were prefer-

entially removed.20-23 Lesions larger than 1 cm were

submitted to biopsy in various sites for representativeinvestigation of the entire lesion.

Stain-retained areas were placed in separate containers,

and the pathologist was not informed of the staining

result. The specimens were fixed in a buffered solution of

10% formalin and submitted to routine procedures

and hematoxylin-eosin staining for analysis by light

microscopy.

The lesions were histologically classified as (1) squa-

mous cell carcinoma: severe dysplasias involving the

entire extent of the epithelium without invasion of the

connective tissue (in situ carcinoma) or with invasion of

connective tissue (frank invasive carcinoma) or limited to

the juxtaepithelial area (initial invasive carcinoma)19,24,25;

(2) epithelial dysplasia: the parameters recommended by

the WHO24 were used; dysplasias were classified as

mild, moderate, and severe; (3) keratosis: the presence ofvarious degrees of keratosis and/or acanthosis with no

epithelial dysplasia or atypical cells; (4) lichen planus:

liquefying degeneration of basal cells, band-shaped

lymphocyte infiltrate in the connective epithelial tissue,

with or without saw-toothed projections, hyperkeratosis,

the presence of Civatte bodies, and separation between

the epithelium and connective tissue26,27; (5) other

benign lesions: lesions without epithelial dysplasia or

atypical cells that are not included among the previously

described groups. The histologic diagnoses were deter-

mined by a previously calibrated pathologist who was

blinded to the toluidine blue results.

In the cases where the tissue analyzed presenteddifferent histologic appearances, the most severe histo-

logic diagnosis was considered.18

The results of the clinical and histologic diagnoses and

the staining results were compared. The sensitivity, speci-

ficity, and the positive and negative predictive results

were calculated according to the method proposed by

Rosenberg and Cretin.12

RESULTSOf the 50 patients studied, 34 were smokers

(23 smoked paper cigarettes, 7 hand-rolled cigarettes,

and 4 pipes), 13 regularly consumed alcohol, and 13 had

related occupational activities that frequently exposed

them to the sun. The clinical diagnosis of the oral lesions

analyzed and the results of staining are presented in

Table II. All superficial ulcerations suggestive of malig-

nancy retained stain. The nonhomogenous leukoplakia

and the erosive/ulcerated lichen planus retained stain

with a higher frequency than did the homogenous leuko-

plakia. There was no retention of stain in the reticular

lichen planus.

The histologic diagnosis and the results of the toluidine

blue staining are demonstrated in Tables III and IV. The

histologic analysis demonstrated that among the lesions

analyzed, 14% (n = 7) were squamous cell carcinomas(1 in situ carcinoma and 6 initial invasive carcinomas).

All retained stain, indicating a 100% sensitivity of

staining for the detection of in situ carcinoma and inva-

sive squamous cell carcinoma, because false-negatives

did not occur. Of the superficial ulcerations, 57.1% (n = 4)

were invasive squamous cell carcinomas, and 15% (n = 3)

of nonhomogenous leukoplakias were carcinomas (1 in

situ carcinoma and 2 invasive carcinomas). Epithelial

dysplasias were detected in 12% (n = 6) of the lesions

536 Onofre, Sposto, and Navarro ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGYMay 2001


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analyzed (4 mild and 2 moderate), yet just 3 retained

stain, demonstrating an occurrence of false-negativeresults and a staining sensitivity of 50% for this group of

lesions. Epithelial dysplasia occurred in 25% (n = 3) of

the homogenous leukoplakias and in 15% (n = 3) of the

nonhomogenous leukoplakias. In 74% (n = 37) of all

lesions evaluated, the histologic analysis revealed an

absence of epithelial dysplasia or atypical cells, and 40%

(n = 20) were lichen planus, 26% (n = 13) keratosis, and

8% (n = 4) other benign lesions (3 granular tissues and 1

ulcerated papilloma). Histologic analysis showed that 9

cases clinically diagnosed as leukoplakia were in fact

plaquelike lichen planus. Among keratosis, lichen planus,and other benign lesions, 13 retained stain; thus 35% of

results were false-positives, indicating a staining speci-

ficity of 65% (Table IV). The highest number of false-

positive results occurred in the lesions clinically diag-

nosed as nonhomogenous leukoplakia (n = 6). According

to the histologic analysis, toluidine blue staining was

positive in 6 cases of lichen planus.

In the total sample analyzed, 26% (n = 13) of results

were false-positives and 6% (n = 3) were false-

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Onofre, Sposto, and Navarro 537Volume 91, Number 5

Table I. Method of application of the 1% toluidine blue staining technique

Oral examination and annotation of location, size, clinical characteristics, and photographing of the lesion

Cleaning of the lesion with a cotton tip soaked in 10% H 2O2 (for the elimination of saliva, food, or tissue remains)

Cleaning of lesion with water jet

Cleaning of lesion with 1% acetic acid


Application of 1% aqueous solution of toluidine blue with cotton tip for 30 seconds


Application of 1% acetic acid with cotton tip for 30 seconds (for elimination of excess of stain)

Oral examination and annotation of location and size of the retained stained areas

Photographing of lesion

Table II. Clinical diagnosis of oral lesions and results of staining

Toluidine blue

Clinical diagnosis n (%) +

Homogenous leukoplakia 12 (24) 2 10

Nonhomogenous leukoplakia 20 (40) 10 10

Reticular lichen planus 4 (8) 4

Erosive/ulcerated lichen planus 7 (14) 4 3Superficial ulcerations 7 (14) 7

Total 50 (100) 23 27

Table III. Clinical and histologic diagnosis of oral lesions and results of staining

Clinical diagnosis

Homogenous Nonhomogenous Reticular Erosive/ulcerated Superficial

leukoplakia leukoplakia lichen planus lichen planus ulcerations

(n = 12) (n = 20) (n = 4) (n = 7) (n = 7)

Histologic diagnosis + + + + +

Squamous cell carcinoma* (n = 7)

Carcinoma in situ 1 Invasive carcinoma 2 4

Epithelial dysplasia (n = 6)

Mild 2 1 1

Moderate 1 1

Benign keratosis (n = 13) 4 4 5

Lichen planus (n = 20) 5 2 2 4 4 3

Other benign lesions (n = 4) 1 3

Total (n = 50) 2 10 10 10 4 4 3 7

*Initial invasive carcinoma.3 granular tissues and 1 ulcerated papilloma.


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negatives. The sensitivity of staining was 72% and the

specificity 65%, the positive predictive value was

43.5%, and the negative predictive value was 88.9%.

DISCUSSIONThe sample investigated in this study was composed

of 86% PMELs and 14% superficial oral ulcerations

suggestive of malignancy, differentiating this work

from the majority of previous works, which include in

their samples few PMELs and a large number of clini-

cally suspected malignancies or typically benign

lesions with no risk of malignancy. Individuals without

lesions (control group) were not included in this study,

because performance of biopsy in normal mucosa not

containing stain retention would not be ethical.

SensitivityStudies have demonstrated that toluidine blue has a

high sensitivity in its detection of malignant oral

lesions; values vary from 84% to 100% (Table V). In

this study, staining was seen to be highly efficient in the

detection of in situ carcinoma and invasive carcinomas,having a sensitivity of 100%, because no false-negative

results occurred among the lesions histologically diag-

nosed as carcinomas. Recently, Warnakulasuriya and

Johnson16 confirmed that oral squamous cell carci-

nomas can be detected with a sensitivity of 100% by

using a commercial rinse containing toluidine blue as

the active ingredient. A study developed by Epstein et al17

evaluated the utility of toluidine blue application

in aiding the recognition and diagnosis of clinically

evident lesions in patients previously treated for oral

cancer and undergoing post monitoring. Toluidine blue

stain identified all in situ carcinomas and invasive

malignant lesions, whereas the clinical examination

identified 78% of the in situ carcinomas or invasive

malignant lesions.

Few studies demonstrated false-negative results incarcinomas, and when they occurred frequencies varied

between 0.9% and 5.5% of the total of the sample

analyzed.5,8,10,11,13 Martin et al28 analyzed the sensi-

tivity of toluidine blue in the detection of epithelial

dysplasia and carcinoma areas in situ and in invasions of

both the normal mucosa as well as the altered adjacent

mucosa of 14 specimens of invasive carcinoma. Forty-

two percent of the results obtained for in situ carcinomas

were false-negatives, and 58% were false-negatives for

epithelial dysplasia. These results are considerably

higher than those presented in the majority of studies.

This discrepancy in results is probably due to the sample

analyzed and to the fact that these authors consideredonly lesions with stippled or dark blue staining as posi-

tive, and those lesions that were weakly stained were

considered as negative. This interpretation differs from

that offered by Mashberg,7,10 who suggested that

doubtful light blue stains should be considered as posi-

tive, at least until biopsy proves the contrary.

Among the lesions diagnosed as epithelial dysplasia

in our study (n = 6), 3 (1 mild and 2 moderate) did not

retain stain and were therefore false-negative results.

The number of cases of epithelial dysplasia was small

in this study, and therefore statistical tests could not be

applied. According to Warnakulasuriya and Johnson,16

false-negative results may occur as a result of a lack of

objective criteria for the evaluation of stain uptake.

Moreover, the exact mechanisms by which the dye

differentially stains malignant or dysplastic tissues

remains unknown. Mashberg10 reported that lesions

with limited dysplasia or atypia did not intensely retain

the stain. Warnakulasuriya and Johnson16 obtained

false-negative results in 26% of the lesions with histo-

logic diagnoses of dysplasia and agreed with the find-

ings of Mashberg.10 Thus, in PMELs some areas of

mild or moderate epithelial dysplasias may not be

detected by staining alone. The use of toluidine blue,

however, should not be excluded, because all in situcarcinomas and invasive carcinomas retain toluidine

blue stain.

SpecificityPrevious studies demonstrated a great variation in the

specificity of staining by toluidine blue of between 44%

and 100% (Table V); this is due to the diversity of lesions

included in the different studies. The lowest specificity

found, 44%, was obtained by us in a previous study.15


Table IV. Histologic diagnosis of oral lesions, resultsof staining, sensitivity, specificity, and positive and

negative predictive values

Toluidine blue

n (%) +

Histologic diagnosisSquamous cell carcinoma 7 (14) 7

Epithelial dysplasia 6 (12) 3 3

Lichen planus 20 (40) 6 14

Keratosis 13 (26) 4 9

Other benign lesions 4 (8) 3 1

Total 50 (100) 23 27

Sensitivity

Carcinoma 7/7 (100)

Carcinoma in situ 1/1 (100)

Superficial invasive

carcinoma 6/6 (100)

Epithelial dysplasia 3/6 (50)

Mild dysplasia 3/4 (75)

Moderate dysplasia 0/2 (0)

Specificity 24/37 (67)

Positive predict ive value 10/23 (43.5)

Negative predictive value 24/27 (88.9)


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This result occurred because we considered in somecases the staining results of the first visit and not the

result of the day of the biopsy 7 to 14 days after the first

consultation. This caused a large number of false-positive

results, generally caused by the retention of stain in

inflammation and trauma areas. To decrease the number

of false-positive results and consequently increase the

specificity of staining, Mashberg8,10 recommends that all

irritating and inflammatory factors should be eliminated

in the lesions that retain stain. These lesions should be

reevaluated and stained after 10 to 14 days, and if the

stain is again retained, they should be considered as

suspicious of carcinoma. For practical reasons some

studies often do not follow this recommendation, conse-

quently increasing the number of false-positives and

reducing the specificity of staining. In this study the

staining specificity was increased to 65% because we

followed the recommendations of Mashberg,8,10 proving

that the variety of results presented in the literature

depends on the methodology used and the sample

analyzed. Our results demonstrated that in the lesions

without epithelial dysplasia or atypical cells, the level of

false-positive results was 35% (n = 13); 6 cases occurred

among the nonhomogenous leukoplakias, 4 among the

erosive/ulcerated lichen planus, and 3 among the superfi-

cial ulcerations suspicious of malignancy. Thus, 100% ofthe false-positive results occurred in lesions with ulcera-

tion or erythema. This result was higher than that

presented by Silverman et al11; they observed that 70% of

lesions with false-positive results presented these charac-

teristics. The higher level of false-positive results may

increase the number of biopsies performed in PMELs

and superficial ulcerations suspicious of malignancy.

This may be beneficial because all PMELs and superfi-

cial ulcerations suspicious of malignancies that do not

respond to treatment should be submitted to microscopicanalysis.22 In addition, the diagnosis of PMELs, based

only on clinical appearance, may lead to a misdiagnosis

and therapeutic errors.19

In this study the high level of false-positive results

led to a reduced positive predictive value. Results

showed that the lesions with retained stain demonstrate

a 43.4% probability of having areas with epithelial

dysplasia, in situ carcinoma, or invasive carcinoma.

The negative predictive value, however, was high, indi-

cating that lesions that do not retain stain demonstrate

an 88.9% probability of not having areas of epithelial

dysplasia or atypical cells. If the cases of carcinoma

only are evaluated this probability is 100%, because

false-negative results did not occur in these lesions.

Another important result to be emphasized is the

high prevalence, 26%, of epithelial dysplasia and squa-

mous cell carcinoma found in this study. Among the

PMELs, the prevalence was 20.9%, occurring predom-

inantly among the leukoplakias, a result similar to that

observed by us in a previous study19 in which the

prevalence found was 17.8%, confirming the necessity

of performing microscopic analysis in all the PMELs.

We concluded that staining with toluidine blue is

highly reliable for the detection of in situ carcinoma

and invasive carcinoma. From our point of view, stainingwith toluidine blue is an adjunct to clinical judgment

and not a substitute for either judgment or biopsy.

Staining should be routinely used as a method to assist

in the choice of biopsy sites and in the follow-up of

PMELs. We believe that toluidine blue serves the

important purpose of accelerating biopsy, particularly

in persistent lesions, and allows the selection of areas

of the lesion more likely to be demonstrated as malig-

nancies or dysplasias. In addition, our clinical experi-

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Onofre, Sposto, and Navarro 539Volume 91, Number 5

Table V. Studies evaluating the application of toluidine blue in oral lesions

Location of No. of lesions Prevalence of Sensitivity Specificity

Study study analyzed carcinoma/dysplasia (%) (%) (%)

Niebel and Chomet1 VH/USA 11 45/55 100 100

Shedd et al2 OM/USA 42 69/3 100 75

Myers4 CH/USA 70 72 100 100

Vahidy et al5 CH/Pakistan 1190 40 86 76Reddy et al6 OM/India 490 92 99 88

Mashberg8 VH/USA 105 49/3 96 95

Mashberg10 VH/USA 179 45/5 90 91

Silverman et al11 OM/USA 132 43/32 98 90

Epstein et al13 CH/Canada 59 41/25 92 63

Onofre et al15 OM/Brazil 44 18/9 92 44

Warnakulasuriya and Johnson16 OM/Sri Lanka 86 21/45 86 62

Epstein et al17 CH/Canada 81 27/28 100 52

Onofre et al OM/Brazil 50 14/12 77 65

The prevalence of carcinoma/dysplasia, the sensitivity, and the specificity were recalculated according to the method proposed by Rosenberg and Cretin.12

VH, Veterans hospital; OM, oral medicine service; CH, cancer hospital.


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ence has shown that the examiner should be experi-

enced in the practice of oral medicine, particularly in

the diagnosis and treatment of precancer and oral squa-

mous cell carcinomas, and should be trained to inter-

pret exactly the results of toluidine blue staining.

We are indebted to the Mario A.S. Paino Laboratory of

Clinical Pathology.

REFERENCES1. Niebel HH, Chomet B. In vivo staining test for delineation of

oral intraepithelial neoplastic change: preliminary report. J AmDent Assoc 1964;68:801-6.

2. Shedd DP, Hukill PB, Bahn S. In vivo staining properties of oralcancer. Am J Surg 1965;110:631-4.

3. Shedd DP, Hukill PB, Bahn S, Ferraro RH. Further appraisal ofin vivo staining properties of oral cancer. Arch Surg 1967;95:16-22.

4. Myers EN. The toluidine blue test in lesions of the oral cavity.Cancer J Clin 1970;20:134-9.

5. Vahidy NA, Zaidi SHM, Jafarey NA. Toluidine blue test fordetection of carcinoma of the oral cavity: an evaluation. J SurgOncol 1972;4:434-8.

6. Reddy CRRM, Ramulu C, Sundareshwar B, Raju MVS, GopalR, Sarma R. Toluidine blue staining of oral cancer and precan-cerous lesions. Indian J Med Res 1973;61:1161-4.

7. Mashberg A. Reevaluation of toluidine blue application as adiagnostic adjunct in the detection of asymptomatic oral squa-mous carcinoma: a continuing prospective study of oral cancerIII. Cancer 1980;46:758-63.

8. Mashberg A. Tolonium (toluidine blue) rinse: a screeningmethod for recognition of squamous carcinomacontinuingprospective study of oral cancer IV. JAMA 1981;245:2408-10.

9. Barrellier P, Rame JP, Chasle J, Souquires Y, Lecacheux B. Ledpistage des cancers de la cavit buccale par le bleu de tolui-dine. Actualitis Odonto-Stomatol 1982;137:87-92.

10. Mashberg A. Final evaluation of tolonium chloride rinse forscreening of high-risk patients with asymptomatic squamouscarcinoma. J Am Dent Assoc 1983;106:319-23.

11. Silverman S Jr, Migliorati C, Barbosa J. Toluidine blue staining

in the detection of oral precancerous and malignant lesions. OralSurg 1984;57:379-82.

12. Rosenberg D, Cretin S. Use of meta-analysis to evaluate tolo-nium chloride in oral cancer screening. Oral Surg Oral Med OralPathol 1989;67:621-7.

13. Epstein JB,Scully C,Spinelli JJ. Toluidine blue and lugols iodineapplication in the assessment of oral malignant disease and lesionsat risk of malignancy. J Oral Pathol Med 1992;21:160-3.

14. Barrellier P, Babin E, Louis MY, Meunier-Guttin A. Utilisation dubleu de toluidine dans le diagnostic des lsions noplasiques de lacavit buccale. Rev Stomatol Chir Maxillofac 1993;94:51-4.

15. Onofre MA, Sposto MR, Navarro CM, Scully C. Assessment ofthe blue toluidine stain in oral lesions with suspicious of malig-nancy. J Dent Res 1995;74:782.

16. Warnakulasuriya KAAS, Johnson NW. Sensitivity and speci-ficity of OraScan toluidine blue mouthrinse in the detectionof oral cancer and precancer. J Oral Pathol Med 1996;25:97-103.

17. Epstein JB, Oakley C, Millner A, Emerton S, Meij E, Le N. Theutility of toluidine blue application as a diagnostic aid in patientspreviously treated for upper oropharyngeal carcinoma. OralSurg Oral Med Oral Pathol 1997;83:537-47.

18. Axll T, Pindborg JJ, Smith CJ, van der Waal I. An internationalcollaborative group on oral white lesions. Oral white lesions withspecial reference to precancerous and tobaccorelated lesions:conclusions of an international symposium held in Uppsala,Sweden, May 18-21 1994. J Oral Pathol Med 1996;49-54.

19. Onofre MA, Sposto MR, Navarro CM, Motta MESFM, TurattiE, et al. Potentially malignant epithelial oral lesions: discrepan-cies between clinical and histological diagnosis. Oral Diseases1997;3:148-52.

20. Mashberg A, Morrissey JB, Garfinkel L. A study of the appear-ance of early asymptomatic oral squamous cell carcinoma.Cancer 1973;32:1436-45.

21. Kramer IRH, El-Labban N, Lee KW. The clinical features andrisk of malignant transformation in sublingual keratosis. Br DentJ 1978;144:171-80.

22. Lamey PJ. Management options in potentially malignant andmalignant oral epithelial lesions. Community Dental Health

1993;10(suppl 1):53-62.23. Scully C. Clinical diagnostic methods for the detection of

premalignant and early malignant oral lesions. CommunityDental Health 1993;10(suppl 1):43-52.

24. World Health Organization Collaborating Center for OralPrecancerous Lesions. Definition of leukoplakia and relatedlesions: an aid to studies an oral precancer. Oral Surg Oral MedOral Pathol 1978;46:518-39.

25. Pindborg JJ, Reibel J, Holmstrup P. Subjectivity in evaluatingoral epithelial dysplasia, carcinoma in situ and initial carcinoma.J Oral Pathol Med 1985;14:698-708.

26. Krutchkoff DJ, Eisenberg E. Lichenoid dysplasic: a distincthistopathologic entity. Oral Surg Oral Med Oral Pathol 1985;30:308-15.

27. Hatchuel DA, Peters E, Lemmer, Hille JJ, McGaw. Candidalinfection in oral lichen planus. Oral Surg Oral Med Oral Pathol1990;70:172-5.

28. Martin IC, Kerawala CJ, Reed M. The application of toluidineblue as a diagnostic adjunct in the detection of epithelialdysplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod1998;85:444-6.

Reprint requests:

Dr Mirian A. OnofreDepartamento de Diagnstico e CirurgiaFaculdade de Odontologia de Araraquara - UNESPRua Humait, 1680Araraquara - So [email protected]


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