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The Role of Direct Visual Fluorescent Examination (VELscope) in Routine Screening for Potentially Malignant Oral Mucosal Lesions
McNamara KK, Martin BD, Evans EW, Kalmar JR
Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114:636-643
Screening for Oral Squamous Cell Carcinoma
Oral squamous cell carcinoma is a common malignant process with a multifactorial etiology. The median age at diagnosis is 62 years, and the most commonly affected sites are the tongue and floor of the mouth. Oral healthcare providers are continuously seeking additional methods of evaluating patients for precancerous and cancerous oral lesions.
Tissue autofluorescence is a recent technology that has been advocated for this purpose. The VELscope device (Visually Enhanced Lesion Scope; LED Dental; White Rock, British Columbia, Canada) is a light source that emits a cone of light in the blue spectrum (400-460 nm), causing fluorophores in the oral tissue to excite and fluoresce when used in the oral cavity. This phenomenon may be visualized directly through a narrow-band filter embedded within the viewing handpiece. According to the manufacturer, areas of reduced autofluorescence (dark areas) are suspicious for precancerous or cancerous tissues in contrast to areas that appear bright green, which is indicative of normal oral mucosa.
A recent prospective study was conducted to evaluate the benefit of direct visual fluorescent examination (DVFE) using the VELscope device in routine screening for potentially malignant oral mucosal lesions in a general population of patients presenting for dental care. A total of 130 patients were recruited for this study and completed the clinical protocol, which consisted of 3 stages:
A comprehensive conventional oral examination completed by 2 examiners with documentation of all mucosal abnormalities;
A DVFE using the VELscope device completed by the same examiner in accordance with the manufacturer's guidelines, noting mucosal tissue with visual fluorescence retention and visual fluorescence loss; and
Completion of a scalpel biopsy and microscopic analysis on any tissue inducing clinical suspicion for precancerous or cancerous change on conventional oral examination and exhibiting visual fluorescence loss on examination with the VELscope device (32 specimens).
Results of the study demonstrated that DVFE failed to identify a single mucosal abnormality that had already been detected by conventional oral examination. Furthermore, 42 of the 130 patients (32.3%) had 1 or more areas of visual fluorescence loss, yet microscopic evidence of precancer or oral cancer was identified in only 1 individual. On the basis of these results, McNamara and colleagues concluded that use of DVFE does not provide diagnostic benefit beyond conventional oral examination alone in routine screening for potentially malignant oral mucosal lesions.
Viewpoint
The results and conclusions of this study support the findings of previous reports on the use of tissue autofluorescence technology. Increased rates of both false-positive and false-negative results have been associated with this technology, which may lead to erroneous diagnoses and inappropriate treatment. The use of DVFE in patients at high risk for development of precancerous or cancerous oral lesions or in surgical margin assessment appears to be more consistent and should be considered for this purpose.
The advent of these devices has raised awareness of the importance of routine oral evaluations on the part of healthcare professionals and the public alike. Unless further research with these devices produces more consistent results, a systematic clinical evaluation of the oral cavity is considered to be the gold standard for early detection of precancerous and cancerous lesions of the oral mucosa.
Abstract