Journal of Oral Biology and Craniofacial Research 10 (2020) 99–103

Contents lists available at ScienceDirect

Journal of Oral Biology and Craniofacial Research

journal homepage: www.elsevier.com/locate/jobcr

The use of Velscope to assess cellular changes occuring in oral T

premalignancy
Sonal Shah∗, Pushkar Waknis, Aditi Saha, Sneha Setiya, Tusha Ratra, Vibha Vaswani
Dept. of Oral and Maxillofacial Surgery, Dr. D.Y. Patil Vidyapeeth, Pune, India

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: To improve visualization of suspicious lesions of the oral mucosa and to assess the accuracy of
Oral premalignant lesions Velscope in assessing cellular changes occurring in oral premalignancy for early diagnosis.
Oral potentially malignant disorders Materials and methods: In this prospective, randomized in-vivo clinical study a total of 250 patients who gave
Velscope history of chewing tobacco were screened. The selection of the site of biopsy was taken based on the area of loss
Autofluorescence
of fluorescence identified by the Velscope within the lesion. Routine blood investigations were done. A biopsy
Non-invasive diagnostic techniques
was performed to confirm the findings of clinical examination. The data was collected and analysed.
Results: Among 200 patients only 110 underwent incisional biopsy. Of these only 89 patients showed neoplastic
changes. Of the control biopsies, none of them showed any dysplastic changes. Out of 106 who exhibited
speckling under autofluorescence, only 89 showed dysplastic changes whereas only 17 showed no dysplastic
changes. Out of these 17 specimens, the histopathological diagnosis of 5 was coated tongue, 3 were pigmented
lesions, 3 were geographic tongue and 2 were mucositis. Of the remaining 4, the histopathological diagnosis of 1
was oral submucous fibrosis, 1 was lichen planus and 2 were frictional keratosis.
Conclusion: False positive findings are possible in presence of highly inflamed tissues, and it is possible that use
of Velscope alone may result in failure to detect regions of dysplasia, but it has its use definitely to improve
clinical decision making about the nature of oral lesions and aids in decisions to biopsy regions of concern. Use of
the scope has allowed practitioners to identify the best region for biopsy. It is much better to occasionally sample
tissue that turns out to be benign than to fail to diagnose dysplastic or malignant lesions. However, poor spe-
cificity is a major limitation for using it as a screening tool.

1. Introduction leukoplakia is diagnosed at an early stage. The early detection and

screening plays a major role in decreasing the morbidity and mortality
The incidence of oral cancer worldwide, is approximately 3% of all of the disease.4,5
malignancies and this is creating a remarkable health problem.1 Oral Early diagnosis of oral malignancy makes the treatment early and
cancer is showing a rise in incidence by every passing year and is being unaggressive and also boosts the survival rate to 80%.6 Oral health care
recognized in the late stage. Late detection and diagnosis can be at- professionals are the ones who detect malignancy and premalignant
tributed to the inadequacy in training of health professionals. Early conditions in the early stages and they make a considerable contribu-
diagnosis of curable precursors of malignancy is still the best way to tion in decreasing the incidence and identifying the high risk patients
make sure that there is improvement in both survival rate and quality of and imparting good healthy habits education to them. By means of the
life, along with the eminent advances in cancer treatment.2,3 Generally, combination of visual examination and palpation, detection of epithe-
the primarily important factor that decides the mortality rate in these lial changes in oral mucosa is the main approach presently and is well
patients is the clinical stage during diagnosis of the same. The diagnosis known to be confined to an impressionistic interpretation. This is then
of oral cancer is influenced to a great extent by not only the patient followed by tissue biopsy with the histopathological assessment that is
reluctance to consult or due to inability to access a health care pro- considered as the gold standard for the diagnosis,7 but this requires a
fessional but also professional delay in diagnosis. The patients’ survival well-trained health care professional and is also believed to be invasive,
rate can be improved if the lesion before its malignant progression from painful, expensive and time consuming. Any approach that makes easy

∗
Corresponding author.
E-mail addresses: sonalbshah@rediffmail.com (S. Shah), [email protected] (P. Waknis), [email protected] (A. Saha),
[email protected] (S. Setiya), [email protected] (T. Ratra).

https://doi.org/10.1016/j.jobcr.2020.03.004
Received 27 January 2020; Accepted 10 March 2020
Available online 14 March 2020
2212-4268/ © 2020 Published by Elsevier B.V. on behalf of Craniofacial Research Foundation.
S. Shah, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 99–103

the visualization of a dubious lesion could help a clinician to detect oral

cancer in its early stages. Hence, the reason why there has been an
evolution of several light induced fluorescence visualization appliances
like the VELscope (Visually enhanced lesion scope), is due to the in-
creased demand for non-invasive tests that will intensify the regular
white light oral examination for the diagnosis of potentially malignant
lesions. This system presents with a sensitivity of 98% and specificity of
96%–100%.8–10 Under a hypothesis, there could exist a molecular dif-
ference in the squamous cell carcinoma occurring in western and
eastern populations. Accordingly there could be a difference in the
behavior of these cells in other aspects also. Thus this study was de-
signed to test the efficacy of VELscope in assessing the cellular changes
occurring in oral premalignancy in Indian population. This study is laid
on the usefulness of the Velscope as a diagnostic aid to assess its efficacy Fig. 2. Lichen planus under blue light. (For interpretation of the references to
in distinguishing the cellular changes in oral premalignancy. colour in this figure legend, the reader is referred to the Web version of this
article.)
The working principle of the Velscope system relies on the loss of
fluorescence in visible and non -visible high risk oral lesions can be
identified by applying direct fluorescence. It comprises of a light source
that emits a wavelength of 400–460 nm and a manual unit for visua-
lization. Green auto-fluorescence is emitted by the normal mucosa
whereas the fluorescent light is absorbed by abnormal areas making
them appear dark, under this light[Figs. 1–6]. Normally occurring
fluorophores in the tissue are a basis for the mechanism of tissue
fluorescence that determine their reflective and absorptive pattern.
Different profile areas undergoing malignant changes in which loss of
fluorescence visualization is seen may maximize on the exposure to
blue light spectra (400–460 nm). Therefore, pre-malignant changes are
diagnosed even before its clinical appearance. Thus the Velscope system
can be used as a complement to visual examination for:

1. Distinguishing between normal and abnormal tissues (both benign Fig. 3. Leukoplakia.
and malignant) is enhanced.
2. Benign and neoplastic changes can be differentiated and/or deli-
neated.
3. Dysplastic or malignant lesions margins that are invisible to the
naked eye under white light can be visualized.9

2. Materials and methods

2.1. Source of data

A prospective, randomized in-vivo clinical study was carried out in

the Department of Oral and Maxillofacial Surgery after receiving ap-
proval from the ethics committee at Dr. D.Y.Patil Dental College and
Hospital, Pimpri, Pune. [Institutional Review Board No. DPU/R&R(D)/
Fig. 4. Leukoplakia under blue light. (For interpretation of the references to
159(8)2013]. colour in this figure legend, the reader is referred to the Web version of this
article.)
2.2. Method of collection of data
positive history of tobacco/pan/supari gutkha chewing and/or smoking
A total of 250 patients who presented to our department with habits were explained about the study and out of these only 200 con-
sented for the research project. They were categorized according to age,
sex, clinical diagnosis when examined in white light and assessing the
cellular changes using Velscope which is the source of blue light
(Table 1). Informed consent was taken before the procedure. The se-
lection of the site of biopsy was taken based on the area of loss of
fluorescence identified by the Velscope within the lesion. Routine blood
investigations were done and a biopsy was performed to confirm the
findings of clinical examination. All the patients were put on a short
course of antibiotics and analgesics after the biopsy. Biopsy was not
done for patients who did not have any clinically visible lesion and also
did not show loss of fluorescence and these patients were re-assured
that no cancerous change was evidently seen in the mouth. However to
obtain the unbiased accurate estimates of the sensitivity and specificity
we scrutinized the control biopsies as a subsample of the areas that
Fig. 1. Lichen planus.

100
S. Shah, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 99–103

➢ Biopsy bottle containing formalin

➢ Needle holder
➢ 3-0 black braided silk
➢ Curved needle
➢ Suture cutting scissors

3. Results

A total of 200 patients, 175 males and 25 females (age range being
between 25 yrs and 65 yrs) who presented to our department with
positive history of tobacco chewing and/or smoking habits were en-
rolled for this study. After a complete visual and autofluorescence ex-
amination, all those patients who showed either clinically visible oral
lesions and/or lack of autofluorescence (n = 113, males- 99 and fe-
males- 14) were advised biopsy. However only 110 underwent inci-
sional biopsy for histopathological assessment. 3 patients did not agree
for biopsy due to fear of the procedure and socio-economic problems.
Fig. 5. Linea alba. Of these 110 patients, only 89 patients showed histopathological pre-
sence of neoplastic changes like dysplasia, carcinoma in situ and
squamous cell carcinoma(Table 2). Of the control biopsies, none of
them showed any signs of dysplastic changes.
We found that out of 106 who exhibited speckling under auto-
fluorescence, only 89 showed dysplastic changes on histopathological
examination whereas only 17 showed no dysplastic changes. Out of
these 17 specimens, the histopathological diagnosis of 5 was coated
tongue, 3 were pigmented lesions, 3 were geographic tongue and 2
were mucositis. Of the remaining 4, the histopathological diagnosis of 1
was oral submucous fibrosis, 1 was lichen planus and 2 was frictional
keratosis. These were clinically visible lesions under white light ex-
amination (Table 2).

4. Discussion
Fig. 6. Linea alba under blue light. (For interpretation of the references to
colour in this figure legend, the reader is referred to the Web version of this The overall 5 year survival rate for oral cancer has remained low at
article.) approximately 50% for the past decade.10 This in part, accounts to the
failure in the early diagnosis of potentially malignant disorders either
Table 1 due to patient ignorance or lack of access of medical services. Thus,
Disease specific profile of patients. (n-110). there is a strong need to improve the diagnostic approaches of the
primary health care professional and the maxillofacial surgeons, also
No. of patients Gender Mean Age in years Clinical Diagnosis
providing less interventional investigations. This area remains an im-
35 M- 30 F-5 43 Leukoplakia portant part of research agenda. As per primitive research, normal from
16 M- 14 F-2 38 Lichen planus malignant tissue can be differentiated using a system that works on
12 M- 11 F-1 52 Oral submucous fibrosis
optical diagnostics where-in light-tissue interactions can be assessed.
4 M- 2 F-2 59 Candidosis
8 M- 08 30 Frictional keratosis
Light based detection systems have been developed to identify tissue
2 M- 02 29 Smokers palate changes which occur in malignancy. One of such optical mechanization
5 M- 05 46 Coated tongue is called autofluorescence which is available in the market by the brand
20 M- 19 F-1 44.5 Erythroplakia name “Velscope”.1,7–9,11 It is a handy device which percieves alterations
2 M- 02 62 Mucositis
in normal fluorescence (apple green hue) which is analogous with
3 M- 03 64 Pigmented areas
3 M- 03 54 Geographic tongue morphological and biochemical changes during cancer development
producing a dark shadow on autofluorescence. Among the many factors
that influence tissue autofluorescence, are tissue construction, light
looked non-dubious in 5 patients. The data was collected and distinc- absorption and dispersion properties of each layer of tissue, the dis-
tions and coalition between the autofluorescence tests and biopsy re- pensation and congregation of fluorophores in the different tissue
ports were examined. The patients were counseled about stoppage of layers, the surrounding environment of the tissue, and its metabolic
the tobacco chewing habit and were followed up for the next three status, the differentiation from benign to neoplastic tissue is attributed
years. to the tissue autofluorescence patterns that reflect changes in tissue
composition. This in itself is a complex phenomenon.12
2.3. Materials used for data collection Velscope is simple to use and noninvasive. It can be utilized by a
vast range of clinicians after a precise duration training and has limited
➢ Velscope and the accessories operator variability. It has no recurrent cost since no consumable re-
➢ Local anesthetic solution agents are needed. It provides real time results and involves less time
➢ 5 cc disposable syringe consuming procedure. It has a high sensitivity for any oral mucosal
➢ 1 inch needle, 25 gauge disorder. However it has a few limitations like high initial setting-up
➢ BP handle and no. 15 blade cost. It requires a dark environment and no permanent record is
➢ Adson's tooth forceps maintained unless photographed (compatible camera is available) and
also has a low specificity for dysplasia. However, the simplicity of use,

101
S. Shah, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 99–103

Table 2
Comparison of autofluorescence results and histopathological assessment.
Diagnosis No.of patients Examination under velscope Histopathological assessment sensitivity Specificity

Leukoplakia 35 All + ve Neoplastic changes evident 100% –

Lichen planus 16 14 +ve 13 - mild dysplastic changes evident 81% 18%
2 -ve 3- no dysplastic change
Oral submucous fibrosis 12 11 +ve 10- mild dysplastic changes evident 83% 16%
1 -ve 2- no dysplastic change
Candidosis 4 3 +ve 3- minimal dysplastic changes evident 75% 25%
1 -ve 1- inflammatory changes seen.
Frictional keratosis 8 All + ve 6 -carcinoma in situ 75% 25%
2- benign tissue
Smokers palate 2 All + ve Carcinoma in situ 100% –
Coated tongue 5 All + ve No dysplastic change 0% –
Erythroplakia 20 All + ve Mild to moderate dysplastic changes evident 100% –
Mucositis 2 All + ve No dysplastic change 0% –
Pigmented areas 3 All + ve No dysplastic change 0% –
Geographic tongue 3 All + ve No dysplastic change 0% –

extensive area imaging potentiality, non-requirement of estranged biopsy specimens. Our results show that Velscope has a high sensitivity
means and the capability to note dispersed lesions impart auto- towards dysplastic and neoplastic changes but indigent specificity is a
fluorescence an effective benefit as a superintendence apparatus. crucial constraint for using this device as a screening tool in a para-
The use of autofluorescence screening in vivo for oral cancer dates mount care setup.
back to the 1980s.12 Early studies have demonstrated inconsistent re-
sults, but the studies conducted in the recent years have reported results 5. Conclusion
which prove a significant improvement over white light examina-
tion.13–27 Only a few oral lesions whereas predominantly laryngeal le- To prevent the progression of oral precancerous lesions and dis-
sions were assessed in these studies. It was evaluated the effect of au- orders to later stages requires sound knowledge and education to detect
tofluoresence of four different wavelengths on freshly resected oral oral cancer at early stages. Hence it is imperative to increase the health
tissue and concluded that the supreme contrast was achieved at the care providers’ depth of knowledge of disease and the latest technology
wavelength of 400 nm.16 Then a handy autofluorescence appliance was of non-invasive detection tools available for early detection of this de-
used and successfully displayed the capability to identify new lesions vastating disease to improve patient prognosis and survival.
and enlarged tumor margins that were imperceptible on white light False positive findings are possible in presence of highly inflamed
examination.17 tissues, and it is possible that use of Velscope alone may result in failure
In our study, all our patients who showed speckling on auto- to detect regions of dysplasia, but it has its use definitely to improve
fluorescence, were under taken for biopsy and we found that out of 106 clinical decision making about the nature of oral lesions and aids in
who exhibited speckling under autofluorescence, 89 showed dysplastic decisions to biopsy regions of concern. Where tissue changes are gen-
changes on histopathological examination whereas 17 showed no dys- eralized or cover significant areas of the mouth, use of the scope has
plastic changes. Out of these 17 specimens, the histopathological di- allowed practitioners to identify the best region for biopsy. It is much
agnosis of 5 was coated tongue, 3 were pigmented lesions, 3 were better to occasionally sample tissue that turns out to be benign than to
geographic tongue and 2 were mucositis. Of the remaining 4, the his- fail to diagnose dysplastic or malignant lesions. However, poor speci-
topathological diagnosis of 1 was oral submucous fibrosis, 1 was lichen ficity is a major limitation for using autofluorescence as a screening tool
planus and 2 was frictional keratosis. These were clinically visible le- in a primary care setting.
sions under white light examination. The sensitivity and specificity was
calculated (Table 2). Funding
Formulas for calculating sensitivity and specificity values of auto-
fluorescence8 Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune.

Sensitivity = No. of true positives/ No. of true positives + No. of false

Declaration of competing interest
negatives

and None.

Specificity = No. of true negatives/ No. of true negatives + No. of false Acknowledgement
positives

Being watchful while surveying the results of autofluorescence None.

screening studies does matter to a great extent, even though total
sensitivity and specificity for constancy purposes were outlined. References
Preferably, the needfulness of the precise gauges of the “true negatives”
and the “false negatives” is needed to acquire the unprejudiced rate of 1. Kharma MY, Alalwani MS, Amer MF. Promising future in the detection of oral cancer
by using advance screening technology. J Oral Health Craniofac Sci. 2016;1 022-33.
the sensitivity and specificity. These can be acquired only by histo- 2. Messadi DV. Diagnostic aids for detection of oral precancerous conditions. Int J Oral
pathologic diagnosis from all the usual areas under white light ex- Sci. 2013;5(2):59 Jun.
amination and autofluorescence. In this study, since taking biopsies 3. Vigneswaran N, Koh S, Gillenwater A. Incidental detection of an occult oral malig-
nancy with autofluorescence imaging: a case report. Head Neck Oncol. 2009;1(1):37
from the whole oral cavity was not a realistic alternative, the control Dec.
biopsies were surveyed as a subsample of the non-suspicious areas 4. Eriksson AT, Corcuera MM, Trapero JC, Sánchez JC, Martínez AB. Analysis of new
under white light examination as well as autofluorescence, in 5 pa- diagnostic methods in suspicious lesions of the oral mucosa. Medicina oral, patología
oral y cirugía bucal. Ed. inglesa. 2009;14(5):1.
tients. Signs of dysplastic changes weren't seen in any of these control 5. Fedele S. Diagnostic aids in the screening of oral cancer. Head Neck Oncol.

102
S. Shah, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 99–103

2009;1(1):5 Dec. 17. Poh CF, Zhang L, Anderson DW, et al. Fluorescence visualization detection of field
6. Luo X, Xu H, He M, et al. Accuracy of autofluorescence in diagnosing oral squamous alterations in tumor margins of oral cancer patients. Nov 15 Clin Canc Res.
cell carcinoma and oral potentially malignant disorders: a comparative study with 2006;12(22):6716–6722.
aero-digestive lesions. Jul 15 Sci Rep. 2016;6 29943. 18. Balevi B. Evidence-based decision making: should the general dentist adopt the use of
7. Rashid A, Warnakulasuriya S. The use of light‐based (optical) detection systems as the VELscope for routine screening for oral cancer? J. Can. Dent. Assoc.
adjuncts in the detection of oral cancer and oral potentially malignant disorders: a 2007;73(7):603 Sep.
systematic review. J Oral Pathol Med. 2015;44(5):307–328 May. 19. Patton LL, Epstein JB, Kerr AR. Adjunctive techniques for oral cancer examination
8. Khan U, Aziz A, Ahmed M, et al. Autofluorescence/A clinical trial: a new hope for and lesion diagnosis: a systematic review of the literature. Jul 1 J. Am. Dent. Assoc.
early detection of oral cancer and oral potentially malignant disorders. Jun 1 2008;139(7):896–905.
Pakistan Oral Dent. J. 2014;34(2). 20. Pavlova I, Williams M, El-Naggar A, Richards-Kortum R, Gillenwater A.
9. Bhatia N, Matias MA, Farah CS. Assessment of a decision making protocol to improve Understanding the biological basis of autofluorescence imaging for oral cancer de-
the efficacy of VELscope™ in general dental practice: a prospective evaluation. Oct 1 tection: high-resolution fluorescence microscopy in viable tissue. Apr 15 Clin Canc
Oral Oncol. 2014;50(10):1012–1019. Res. 2008;14(8):2396–2404.
10. Venugopal C, Nazeer SS, Balan A, Jayasree RS. Autofluorescence spectroscopy aug- 21. Roblyer D, Kurachi C, Stepanek V, et al. Objective detection and delineation of oral
mented by multivariate analysis as a potential noninvasive tool for early diagnosis of neoplasia using autofluorescence imaging. May 1 Canc Prev Res. 2009;2(5):423–431.
oral cavity disorders. Dec 1 Photomed. Laser Surg. 2013;31(12):605–612. 22. Jayaprakash V, Sullivan M, Merzianu M, et al. Autofluorescence-guided surveillance
11. Laronde DM, Williams PM, Hislop TG, et al. Influence of fluorescence on screening for oral cancer. Nov 1 Canc Prev Res. 2009;2(11):966–974.
decisions for oral mucosal lesions in community dental practices. J Oral Pathol Med. 23. Huff K, Stark PC, Solomon LW. Sensitivity of direct tissue fluorescence visualization
2014;43(1):7–13 Jan. in screening for oral premalignant lesions in general practice. Gen Dent.
12. Epstein JB, Güneri P, Boyacioglu H, Abt E. The limitations of the clinical oral ex- 2009;57(1):34–38 Jan.
amination in detecting dysplastic oral lesions and oral squamous cell carcinoma. Dec 24. Koch FP, Kaemmerer PW, Biesterfeld S, Kunkel M, Wagner W. Effectiveness of au-
1 J. Am. Dent. Assoc. 2012;143(12):1332–1342. tofluorescence to identify suspicious oral lesions—a prospective, blinded clinical
13. Reichart PA. Oral mucosal lesions in a representative cross‐sectional study of aging trial. Dec 1 Clin Oral Invest. 2011;15(6):975–982.
Germans. Community Dent Oral Epidemiol. 2000;28(5):390–398 Oct. 25. Balevi B. Assessing the usefulness of three adjunctive diagnostic devices for oral
14. Thomson PJ. Field change and oral cancer: new evidence for widespread carcino- cancer screening: a probabilistic approach. Community Dent Oral Epidemiol.
genesis? Jun 1 Int J Oral Maxillofac Surg. 2002;31(3):262–266. 2011;39(2):171–176 Apr.
15. Wax A, Yang C, Müller MG, et al. In situ detection of neoplastic transformation and 26. Pierce MC, Schwarz RA, Bhattar VS, et al. Accuracy of in vivo multimodal optical
chemopreventive effects in rat esophagus epithelium using angle-resolved low-co- imaging for detection of oral neoplasia. Jun 1 Canc Prev Res. 2012;5(6):801–809.
herence interferometry. Jul 1 Canc Res. 2003;63(13):3556–3559. 27. Takano JH, Yakushiji T, Kamiyama I, et al. Detecting early oral cancer: narrowband
16. Svistun E, Alizadeh‐Naderi R, El‐Naggar A, Jacob R, Gillenwater A, Richards‐Kortum imaging system observation of the oral mucosa microvasculature. Mar 1 Int J Oral
R. Vision enhancement system for detection of oral cavity neoplasia based on au- Maxillofac Surg. 2010;39(3):208–213.
tofluorescence. Head Neck: J. Sci. Spec. Head Neck. 2004;26(3):205–215 Mar.

103