Early Detection of Oral Cancer: Is Velscope Reliable?

velscope.jpgI have taken 2 courses in the early detection of oral cancer. In one of these courses, the lecturer made a strong case for using the VELscope to detect oral cancer at such an early stage that no other signs were apparent, other than the characteristic appearance under the VELscope. He presented numerous cases of early detection confirmed by biopsy. In another course, taught by an oral surgeon, the emphasis was on visual inspection and referral for biopsy when needed. He felt the VELscope was not reliable. What is the experience of the readers who are VELscope users? What about other technologies, such as OralCDx, for the early detection of oral cancer? Are these technologies reliable and useful? Thanks.

Editor’s Note:
According to the VELscope:

“VELscope is a revolutionary hand-held device that provides dentists and hygienists with an easy-to-use adjunctive mucosal examination system for the early detection of abnormal tissue. It is based on the direct visualization of tissue fluorescence and the changes in fluorescence that occur when abnormalities are present.

The VELscope Handpiece emits a safe blue light into the oral cavity, which excites the tissue from the surface of the epithelium through to the basement membrane (where premalignant changes typically start) and into the stroma beneath, causing it to fluoresce. The clinician is then able to immediately view the different fluorescence responses to help differentiate between normal and abnormal tissue. In fact, VELscope is the only non-invasive adjunctive device clinically proven to help discover occult oral disease.”

27 thoughts on “Early Detection of Oral Cancer: Is Velscope Reliable?

  1. As a periodontist who has done oral soft tissue exams for my entire career as a dentist I was skeptical when my friend, Dr. Ray Bertolotti loaned me his VELscope because he was going to be out of town. He felt that this should be the standard of care for all specialists. Well, I checked out the technology and started using it. I have found lesions that were confirmed oral cancer only 3 times in my entire 27 years as a dentist so I do not expect to see much with the VELscope either. BUT that said, I am more sure that things ARE negative now. AND that first week with Ray’s VELscope I saw several patients that had begnign lesions that we had been observing. I feel much better when they show up VELscope negative!! SO, I bought 2 of them and use them on all new patient exams and also on my annual or biannual check ups.

    Comparing to Visilite and Orascoptic DK, this technology is so easy to use! The upfront cost is steep but over time the VELscope ends up being more affordable as far as time and money. Oral CDx is great when you find something suspicious but with VELscope ruleouts you don’t need to do that as routinely.

    I personally don’t charge a separate fee for the VELscope because I don’t want cost to enter the patient’s decision as to whether or not to have the exam. I also feel that our practice should provide the highest level of care, incorporating the latest technology.

  2. This is the best piece of equipment I have ever purchased. Patients love the reassurance it giveswhen we use it routinely. Our oral surgeons were initially sceptical and said a good visual check is all you need but Velscope finds things before you can see them with the naked eye and they are now trialing the Velscope. I personally think all dentists, general or specialists, should have one of these in their practice and use them regularly on all their patients as we do.

  3. Thank you for raising this question. I am not sure if the gentleman asking this question attended one of my courses or not, but the course content sounds remarkably familiar. I was originally very skeptical about the VELscope because I was disappointed with the other systems for early detection that I had been using. My hygienist convinced me to purchase one. Now, I am sponsored by LED Dental (makers of VELscope) and HenrySchein to speak about early oral cancer detection.

    In my courses, I try to very hard to be very objective about these technologies, and I have permission from each company to discuss their products, which is unique. I would encourage anyone interested to come to the Ohio AGD MasterTrack course, held at the OSU College of Dentistry on October 3-4, 2008. (http://www.dent.osu.edu/ce/pages/show_course.php?course_id=09.04). One day will be an intensive review of early oral pathology with Dr. Michael Kahn, the chairman of Tufts Oral Pathology. The second day will be a thorough review of current early detection technologies, as well as hands-on biopsy techniques with pig tongues.

    Currently, a draft is being prepared for publication showing that the VELscope dramatically reduced the amount of false positives in my practice over 1 year compared to the previous year in which only a white light clinical exam was used. In a nutshell, I missed 10 dysplasias without the VELscope, all of which were considered by the pathologist to be “premalignancy potential uncertain.”

    I hope this information is helpful to you.

  4. So far I have only heard that the Velscope only makes the doctors and patients feel better. I would be interested in data that shows that it works. I do not doubt that it is easy to use but I am looking for data that shows that it works, Will it detect Ca in situ. It detects cell changes but will it indicate squamous dyplasia or atypia or melanocytic atypia and does it work on skin or just mucous membranes?

  5. Velscope is an oral cancer SCREENING device…It does not diagnose cancer or squamous dyplasia or atypia or melanocytic atypia or Ca in situ. The only way to prove that the abnormal tissue is cancerous is through byopsy performed by the appropriate specialist. It is however the only non-invasive screening device that as been approved by the FDA for not only finding the area of abnormal tissue but for helping locate the margin for surgery.
    It is a mis-conception to most Dr’s that this device will determine whether or not the lesion is cancerous or not.
    It just simply aids in finding abnormalities not visible to the naked eye.

  6. The new Velscope, recently cleared by the FDA, is an easy, noninvasive way to detect early on oral, or mouth cancers, before they get to the advanced stage. I read that Velscope does not actually diagnose the cancer but it detects areas that appear suspicious.

  7. I am a Board Certified Oral and Maxillofacial Surgeon with extensive oral pathology training. When i originally heard of the velscope I too was somewhat skeptical and thought it another costly gadget. After much review of research on the scope and technology and testimonials from other doctors I purchased one. Well let me tell any of you. This scope has raised the standard of examination care in my office. I have since found lesions that were otherwise not clearly visable to the naked eye under regular room light. I think it is a higher tier to “standard of care”.

  8. I have used the VELscope over the las two months, and it has certainly revolutionised my practice, which is Public Hospital based H&N work. It is a screening tool, and its limitation is purely dependent on where you can get the illumination going. A dark room is very preferable, and yes, tonsillar lesions have been detected in my clinic.

    I agree that this tool requires to become the first line of assessment – its head and shoulders above other tools along these lines.

  9. Previously, I posted an encouragement for those interested in this blog to attend high-quality continuing education. Since then, I have had the opportunity to share courses in several venues in the United States and Canada. My experience has taught me a very important lesson…. There is a significant need for quality continuing education about oral cancer early detection!

    I can firmly reaffirm the comments by other bloggers. Since others have confirmed what I have reported in various articles, I can only suggest that those that are opposed to the use of VELscope speak out of a lack of current knowledge. As I have reported, direct tissue fluorescence visualization helped me identify 10 dysplasias in my average, low-risk general dental practice:

    Huff,K,Stark,P,Solomon,L. Sensitivity of direct tissue fluorescence visualization in screening for oral
    premalignant lesions in general practice. Gen Dent. January/February, 2009. 34-38.

    For clarification of adjunctive oral cancer screening systems, please read my letter to the editor of JADA in response to an article in 2008:

    J Am Dent Assoc, Vol 139, No 10, 1304-1306.
    © 2008 American Dental Association

    “CANCER SCREENING
    Facilitating clinicians in performing oral cancer screening examinations should be encouraged to identify occult, or further affirm the presence of potentially premalignant, dysplasias. Although specialists who see small precancerous lesions on a regular basis may object to the use of adjunctive screening technologies, it is my opinion based on my clinical experience, personal research and discussions with my colleagues, that they are valuable screening and decision-making tools for the majority of dental professionals when used appropriately in conjunction with a conventional examination.

    Some of the facts about adjunctive screening tools may not have been clear in the July JADA article, “Adjunctive Techniques for Oral Cancer Examination and Lesion Diagnosis: A Systematic Review of the Literature,” by Dr. Lauren Patton and colleagues ( JADA 2008;139[7]:896–905 ). For example, none of the tools mentioned is reported to be diagnostic; according to manufacturers’ statements, they are only screening adjuncts. Diagnosis can only be made via histological examination of a surgical biopsy specimen.

    There should be a distinction made between visual screening systems and brush testing, which involves tissue sampling. The Vizilite (Zila Pharmaceuticals, Phoenix), the Microlux DL (AdDent, Danbury, Conn.) and the Orascoptic DK (Orascoptic, a Kerr Company, Middleton, Wis.) all use tissue reflectance with the assistance of an acetic acid rinse. All of these systems are indicated for amplifying the visualization of white or mixed lesions by reflectance of light off the superficial mucosal layers.

    The VELscope (LED Dental, White Rock, British Columbia, Canada) uses no prerinse and is based on direct tissue fluorescence, which uses the metabolic properties of tissue growth to assist in identifying irregular tissue metabolism. According to the article, “tissue fluorescence in the oral cavity is variable and is affected by structural changes, metabolic activity, the presence of hemoglobin in the tissue, vessel dilatation … .” However, the statement becomes obscure: “… and, possibly, inflammation.”

    If it is affected by the presence of hemoglobin and vessel dilation, then that is inflammation. The VELscope will identify localized inflammation, but diascopic blanching,1 a technique described on the VELscope training DVD, can be effective if done properly in differentiating inflammatory lesions from persistent lesions that may be premalignant.

    To the best of my knowledge, the variability of tissue appearance has not been defined for acetowhite lesions detected with the Vizilite or with the VELscope to date. That expectation probably is as unrealistic as is quantifying the variation of healthy tissues under incandescent light inspection.

    In my own experience, tolonium chloride is difficult to procure for routine clinical use, is technique-sensitive and has questionable repeatability for the same lesion in the same person. However, I know that a commercially prepared tolonium chloride solution is available only as part of the Vizilite Plus system. Interestingly, a recent publication gave an example photographically in which tolonium chloride failed to identify the full extent of dysplastic tissue compared with the extended margin identified by direct tissue fluorescence,2 which makes me question its predictability as a screening tool.

    Physical examination in good lighting has been defended as the preliminary level of screening. Adjunctive visual screening technologies are available as a secondary level of screening for enhancing the clinician’s screening skills. Brush biopsy (Oral CDx; Oral CDx Laboratories, Suffern, N.Y.) may be a tertiary screening level, used for patient education and for supporting the use of surgical biopsies, as could liquid-based brush cytology, a viable alternative3 that was not discussed in this article. Only surgical biopsy will yield a definitive diagnosis.

    REFERENCES

    Rudd M, Eversole R, Carpenter W. Diascopy: a clinical technique for the diagnosis of vascular lesions. Gen Dent 2001;49(2): 206–209.[Medline]

    Williams PM, Poh CF, Hovan AJ, Ng S, Rosin MP. Evaluation of a suspicious oral mucosal lesion. J Can Dent Assoc 2008;74(3): 275–280.[Medline]

    Mehrotra RG, Gupta A, Singh M, Ibrahim R. Application of cytology and molecular biology in diagnosing premalignant or malignant oral lesions. Molecular Cancer 2006;5:11. Published online March 23, 2006. “www.molecular-cancer.com/content/pdf/1476-4598-5-11.pdf”. Accessed Sept. 9, 2008.[Medline]”

    Respectfully submitted,

    Kevin D. Huff, DDS, MAGD

  10. While I do appreciate the editor’s note “Please refrain from promotional comments”, most of the responses feels like a VELscope marketing meeting, with pieces of their brochure spit back at us.

    Like Barry Shipman, the oral surgeon above, I would also like to find out more about it’s effectiveness with dysplasia and atypia. How does the VELscope find dysplasia, when dysplasia is a microscopic diagnosis which can only be made by looking at cells (not at light coming from the mucosa)?

  11. There are a few comments in this forum that correctly state that the VELscope is not a test. “It is a
    mis-conception to most Dr’s that this device will determine whether or not the lesion is cancerous or not.” Which is accurate. But then, those are followed up with comments like “I feel much better when they show up VELscope Negative”. Or “OralCDx is great when you find something suspicious but with VELscope ruleouts you don’t need to do that as routinely.” “VELscope Negatives”? …”VELscope Ruleouts”?. You can understand how someone can get the wrong idea. These are scary, confusing phrases. How can it rule out anything with certainty if it’s not diagnostic? I can’t stress enough that unless a biopsy tells you that it’s negative, you don’t know for sure.

    If a VELscope indicates that something is positive, and it isn’t, someone had a biopsy and they’re okay. If you use the VELscope (or other screening aid) and send someone home because the VELscope didn’t “fluoresce” and you got a “VELscope negative”, someone can leave your office with cancer, or abnormal cells that may become cancer. Only a biopsy can “definitively” tell you what you’re looking at – brush or scalpel.

    Screening for oral cancer is essential. Anything that helps dentists do that more often, and better is great. But you are doctors, and dental professionals – ask questions. What makes sense? Learn when to use a screening aid, and when to use a tissue test. They are not the same, and shouldn’t be used the same way. The surgical biopsy IS the gold standard. But who’s going to send every patient with an unexplained spot in their mouth to the surgeon?

    The brush biopsy doesn’t compete with the scalpel. It painlessly bridges the gap between seeing something during an exam and a referring to the oral surgeon. You do the brush biopsy to know that it’s not dysplasia or carcinoma – and to find out what you should do next. You do the scalpel to get more specific information about which stage it’s at once it’s been determined that further investigation is necessary. Remember, we’re not talking about scary and “highly suspicious” things here. Those should go straight to the oral surgeon. But why subject a patient for a surgical procedure if it’s not warranted.

    I hope this help clarify things for the person who asked the original question.

  12. What is the cost of the Velscope? What is a reasonable charge for having this type of screening in an annual checkup?

  13. I used to use Vizilte and switched to the VELscope because it seemed like the thing to do. It never really did anything for me, but honestly, it seemed like a faster, more efficient (and profitable) way to do an oral cancer screening. The things that I read, and reps at the tradeshow booth said that the VELscope was very accurate.

    Well…I just got my February issue of the JADA and my world is rocked. I was using the VELscope to give my patients what I was led to believe was the best standard of care using highly accurate technology. The clinical study about Vizilite and VELscope said that it’s wrong almost half the time. How is that reliable?

    Now, what am I supposed to do with this gadget? This is crazy. First my Toyota, and now this.

  14. Dennis S. I have the Velscope and I read the same article. In my opinion, I would rather be cautious and wrong 50%, than not use it and miss something that I had a 50/50 chance to detect. I sleep better at night knowing that I didn’t let the other 50% slip through my fingers and having one of my patients die because i didn’t use the technology. (Sorry about your Toyota)

  15. Has anyone else had problems with the new Velcaps. I find that they are flimsy and fall off a lot. When questioned about this the company said that I must be putting them on wrong but how can you do that, if you are just supposed to slip them on with no turning? This is one of those instances where an improvement screwed up a good product.

  16. VELscope and Vizilite are great products, but they are so last year! The newest and latest technology, which is similar to the VELscope, is the Identafi 3000. It’s revolutionary fluorescence and reflectance technology employs 3 unique wavelengths of light that can detect oral cancer with greater efficacy than the rest. Identafi 3000 is also approved by the FDA. If you are interested in learning more, call 303-435-3906.

  17. Dave S,

    I wish I could agree with you, but think about it. VELscope doesn’t find 50% more things than we would have caught doing a good visual exam with a regular white light. A sensitivity of 50% means that we can’t examine a patient and rely on what the VELscope tells us. It will be wrong half the time.

    It didn’t bother me so much if I sent a few extra people to the oral surgeon when they didn’t need to go. What bothered me, was that when I was telling my patients that they were okay…”nothing to worry about”…that may not have been true for 5 out of 10 of my patients. 5 out of 10! And that’s what was unacceptable.

    By the way, Dana, when this article came out I looked at the Identifi 3000. It’s based on the same technology as the VELscope. (Yes, I know, with one extra color light that reduces false positives). Unfortunately, it uses autofluorescence (the VELscope technology), to find oral cancer. And that’s what the JADA article said has a sensitivity of 50%. So, it will still miss 50% of what we’re supposed to be looking for.

    I recently took an oral pathology CE course and re-learned how to do a “better” oral exam. I highly recommend it. Now I have an understanding of the early signs of oral cancer and how it starts (I think I slept through parts of oral path in school). The course gave me confidence. Since I can’t rely on the technology that’s supposed to aid me…I have to rely on myself.

    My patients trust me. I think this is the least I could do.

  18. I only became aware of VelScope when I went to my last cleaning/exam. I was presented with what I believe was either an “informed consent” sheet or a sales sheet about VelScope screening. The items requiring my initials were mostly straight off the VelScope published materials: survival rate, rate if caught early, low % of cases caught early, etc. There was no information on diagnostic limitations, effectiveness, false positives, etc. For those with the device – it this something that was directly provided (verbatim or a suggested template) by VelScope? If not, do you provide/require an such a sheet to your patients?

    Thanks,

    J

  19. My dentist recently purchased a VelScope, and has be strongly encouraging his patients to be screened with it – for a fee ($45). Is this standard practice among dentists? I’ve read numerous comments that the VelScope is now part of the standard exam provided, and at least one which indicated that there was no fee since the doctor would not want that to be factored into a patient’s decision to be screened or not. I like my dentist, but his strong (almost guilt-provoking) way of going about it is off-putting.

  20. I read with interest the above comments regarding the VELscope. An review of this system is soon to be published on the Dental Hub of Health Imaging Hub. In advance of this review I would like to offer up the article: A cross-sectional study evaluating chemiluminescence and autofluorescence in the detection of clinically innocuous precancerous and cancerous oral lesions, authored by R Mehrotra et al in the Journal of the American Dental Association 2010, Feb. Without going into the specifics of their methods and the results, what they found was a sensitivity of 50% and a specificity of 38.9 percent. These values would not be considered adequate for cancer screening by any stretch of the imagination. Clinicians should consider this in their purchasing decisions.

  21. I read the Jada article, and a response to it put out by Vizilite. Vizilite highlighted some significant issues with the Jada report that made me question the report’s credibility as it pertained to Vizilite. Also, Jada reviewed Vizilite just a few years prior, and considered it to be an effective oral cancer screening technology..even noted that it had 100% sensitivity. Odd that the exact same technology is suddenly not effective…

    Anyway, what made me select to use Vizilite was a British Columbia study that..and I’m paraphrasing…after following patients, who had a false positive toludine blue exam, 80% of the patients ended up with oral cancer within 4 years. I’ve looked into all the oral cancer screening products on the market, and only Vizilite has an FDA approved toluidine blue dye incorporated into their product. That sold it for me, and it’s why I’ve included in my practice. In my own pratice, I’ve found that the toluidine blue stains the areas of a lesion that are more likely to be precancer or cancerous cells a darker blue. This means that my oral surgeon knows where on the lesion to take his biopsy. Again, Vizilite is the only one that has this ability…it’s really not about which product has the brightest “light”..it’s about which one has toluidine blue!

  22. An office where I perform oral and maxillofacial surgery just purchased a light. Since they will refer cases to me based on the use of their light, I thought it only appropriate to research this subject. Very interesting topic. No one has posted an actual case report or mentioned any published case report. I urge proponents of this form of oral cancer screening to publish. If you are not familiar with the “how to” of publishing or need some assistance in preparing a manuscript, please feel free to contact me at specializeddentistry.net

  23. I looked at both Velscope and Identafi, but I am still undecided about which one to choose. Any one currently using Identafi?

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