The VELscope and False Positives For Oral Cancer

By David Morgan, PhD

The VELscope and “False Positives”

Our team speaks with dental practices on a daily basis about the VELscope and how it should be used together (that is “adjunctively”) with the comprehensive oral examination (COE) to enhance their ability to visualize oral mucosal abnormalities. One question we get from some practices is whether the VELscope produces “false positives” for oral cancer. The answer to this question is no – the reasoning relies on a basic understanding of the difference between a clinical examination and a diagnostic procedure. Let’s take a closer look at the VELscope and its indications for use in order to understand the relationship between the comprehensive oral examination, the adjunctive fluorescence examination with the VELscope and diagnosis.

Understanding the COE, VELscope Exam and Diagnosis

First and foremost, it is critical to understand that the comprehensive oral examination (COE) and the adjunctive intraoral fluorescence examination with the VELscope are intended to screen for any type of oral disease warranting further attention and clinical follow-up. There are very many kinds of oral mucosal abnormalities that may present to the clinician in addition to pre-cancer (dysplasia) and oral cancer. Some examples of these are provided below:

• Trauma
• Chemical irritation
• Medication side-effects
• Allergic responses
• Thermal damage
• Fungal, viral or bacterial infections
• Autoimmune disorders affecting the oral mucosa
• Systemic conditions with oral manifestations
• Developmental/ congenital abnormalities

Although, unlike cancer, most of these are not life threatening they all require appropriate identification and many require active therapeutic intervention and follow-up. The main purpose of the COE and the adjunctive VELscope exam is to find these abnormal areas. It is the clinician’s job then to ensure that these abnormal areas are followed up on, appropriately diagnosed, treated if appropriate and resolved.

Typically based on visual and tactile clues provided by the COE and VELscope exam, the clinician can form a “differential diagnosis” – a list in decreasing order of likelihood of what the abnormality could actually be; e.g. dysplasia, trauma, allergic response, etc. The next best course of action relies on the clinical judgment of the clinician and can involve a variety of possibilities:

• Schedule a follow-up appointment to see if the abnormality resolves of its own accord
• Take some action to address the presumed cause of the lesion (anti-fungal treatment, recommend change in patient’s oral habits, etc.) and schedule a follow-up appointment to see if the abnormality has resolved
• Biopsy in the office if clinically appropriate
• Immediate referral to a specialist for a biopsy for a pathological diagnosis of the abnormality – this last option would be preferred if the clinician strongly suspects dysplastic or cancerous changes

Here are the key takeaways:

1. The VELscope is firmly part of the examination portion of the process – its role is to enhance the visualization of abnormalities that may not be apparent or even visible with the COE and thus reduce the possibility of an abnormal area being missed. The characteristics of the lesion using fluorescence provides additional information to the clinician that may be useful in forming the differential diagnosis. In fact, a study published in the Journal of Oral Pathology and Medicine¹ concluded that the visual information provided via tissue fluorescence can be utilized to aid in the assessment of oral abnormalities and significantly contribute to the referral decision-making process.
2. The only diagnostic procedure discussed here is the biopsy which remains the gold standard for the diagnosis of oral mucosal dysplastic lesions or cancer.
3. Neither the COE nor the adjunctive VELscope exam are definitive diagnostic tests. A clinician does not perform a COE or a VELscope exam and emerge with a positive or negative “result” for oral cancer or dysplasia.

Does the VELscope Produce False Positives For Oral Cancer?

To conclude, the reason that the VELscope does not produce false positives is that there are no well-defined positive or negative outcomes of a VELscope examination. Similarly, there are no well-defined positive or negative outcomes of a comprehensive oral examination. Neither of these exams intended to generate positive or negative results specifically for cancer since they are looking at all types of oral disease. When these exams are considered in the context of how they are used in real life as we have done here, this is completely self-evident.

Part of the confusion on this issue has resulted, in our opinion, from the term “oral cancer screening exam” being used as a name for the COE and as a way to describe the VELscope examination. This has helped spread the incorrect notion that COE’s and VELscope exams are specific to oral cancer. Although part of the function of the COE and the VELscope exam is to assess for the presence of signs of oral cancer, as we have seen, that is not all they are intended for.

If you would like more information on the VELscope, we are here to help. Click the button below to reach our team or call 877.278.3799.

¹ J Oral Pathol Med. 2014 Jan;43(1):7-13. doi: 10.1111/jop.12090. Epub 2013 Jun 10.