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Articles by Dr. Comisi

Oral human papillomavirus lesion identified using VELscope instrumentation: Case report By John C. Comisi, DDS, FAGD Featured in General Dentistry, September-October 2008 Pg. 548-550
Posted on Friday, September 05, 2008
The role of oral human papillomavirus (HPV) in the incidence of oral carcinoma has increased among traditional non-risk patients under the age 40.  This case study describes how a squamous papilloma (attributed to the HPV) was discovered using the VELscope oral screening device.  Photographs of the lesion that might help dentists to identify these areas, using both white light and fluorescence visualization with VELscope, are included.

Received:  November 6, 2007
Accepted:  February 8, 2008

 
The incidence of oral cancer in typically non-risk patients is on the rise; since 1973, the incidence of tonsillar and base-of-tongue cancers has risen annually in the U.S.1  In a 2007 study, D’Souza et al noted a strong association between oral human papillomavirus (HPV) infection and oropharyngeal cancer, regardless of whether the subjects had the established risk factors of tobacco and alcohol use.1  Corcoran and Whiston reported an almost fivefold increase in oral cancer patients under the age of 40, many of whom lacked traditional risk factors; a viral etiology has been suggested.2  According to Schantz and Yu, the majority of these viral lesions appear on the tongue.3 

The VELscope (LED Dental Inc., White Rock, British Columbia, Canada; 888.541.4614) uses direct tissue fluorescence visualization, a noninvasive technique for assessing the chemical and morphologic composition of oral mucosal tissue.  Fluorescence excites tissue by using a light at a specific wavelength, which in turn causes the tissue to emit its own light (this is called natural fluorescence).  Natural fluorescence cannot be seen with the naked eye in normal white light, since it is much dimmer (by several orders of magnitude) than other wavelengths that the eye can see.  The VELscope produces a blue light that excites the oral mucosal cells; when viewed through the VELscope handpiece, healthy cells will fluoresce back.  When viewed with the VELscope’s proprietary filter system, these healthy cells will appear green in color.  Damaged and unhealthy cells will not fluoresce and thus appear as black or dark maroon areas against the green surrounding tissue. 

It is hoped that using this device in the dental office will make it possible to identify potential oral cancer areas well before they can invade the basement membrane, which would reduce the incidence of oral cancer.  However, this device has a learning curve that must be understood in order to get the most benefit for the clinician and the patients that are being screened.  The clinician must understand how normal healthy tissue will appear when viewed with the VELscope.  Each type of oral tissue can and will have a unique appearance when viewed with the VELscope.  Once the clinician is familiar with the normal appearance of the oral tissue, tissue that may be abnormal and dysplastic can be identified more readily.  Some signs that otherwise would be overlooked upon routine oral examination are plainly revealed when viewed through the VELscope; however, some areas may require further investigation. 
 
Case report
A 37-year-old woman came to the office in November 2006 for a periodontal maintenance visit and examination.  Routine examination revealed a lesion on the left lateral border of the tongue measuring approximately 3.0 mm x 4.0 mm (Fig. 1 and 2).  The lesion was a circular, slightly erythematous area surrounded by a white keratin border.  The patient admitted that she had smoked 0.75 packs of cigarettes a day since she was 12 and there was concern that the lesion might be associated with her smoking.  The VELscope was utilized and while the lesion did not demonstrate a loss of fluorescence as would have been expected with a potentially dysplastic lesion, it did have a white keratinized irregular border and a slightly darker center area.  To rule out the possibility that the area was associated with benign migratory glossitis, the patient was asked to return in one month to see if the lesion had moved or had run its course and disappeared.
 

 
 

 
At the follow-up appointment four weeks later, the lesion had not moved but had grown to approximately 6.0 mm x 6.0 mm (Fig. 3).  The area still did not demonstrate a loss of fluorescence when viewed with the VELscope (Fig. 4).  The keratinized border was still present and the center of the lesion was slightly darker but still not the dark black that would be associated with a pathologic lesion.  Based on the patient’s history, it was decided that the lesion should be evaluated and removed by an oral surgeon.  This surgery was performed in December 2006. 
 
 

 
The surgeon’s biopsy report mentioned that the specimen consisted of a variegated, tan, focally hemorrhagic mucosal fragment (0.8 x 0.6 x 0.3 cm).  The margin was inked.  The specimen was sectioned serially and submitted entirely in one cassette.  The report indicated an inflamed squamous papilloma; however, no dysplasia was identified.

Neither the patient nor the author were satisfied with the inconclusive results.  What was the cause of the inflamed squamous papilloma?  The etiology of squamous papilloma is local trauma and HPV.4  Since it had been determined that the lesion was not induced traumatically, the possibility of HPV and its potential ramifications (that is, increased risk of oral cancer, recurrence if excision of the virus was inadequate) were discussed.  The patient decided to consult with her primary care physician (to better understand what might be happening) and to visit a local otolaryngologist.  The otolaryngologist’s report is presented in the table.
 
 
 
Discussion
Utilizing the VELscope to observe an unusual area can lead to the early intervention and removal of a potentially dangerous oral lesion.  In the present case, suspicions were raised because of the patient’s history of chronic tobacco use.  However, every oral lesion should be evaluated, even if it appears unremarkable, as such lesions may be HPV-induced.  The patient in the present case has returned for quarterly recall visits, primarily because of periodontal maintenance needs, and has been evaluated with the VELscope at each of these appointments.  Fifteen months after surgery, no other suspicious areas have developed.
 
Summary
The unusual appearance of the lesion under VELscope illumination and the etiology of the lesion determined as a result were eye-opening.  When used properly, the VELscope can highlight areas that otherwise might be dismissed as “normal” and ignored (which would could increase the risk of future disease).
 
Author information
Dr. Comisi is in private dental practice in Ithaca, New York.
 
References
1.   D’Souza G, Kreimer AR, Viscidi R, Pawlita M, Fakhry C, Koch WM, Westra WH, Gillison ML.  Case-control study of human papillomavirus and oropharyngeal cancer.  New Engl J Med 2007;356:1944-1956.
2.   Corcoran TP, Whiston DA.  Oral cancer in young adults.  J Am Dent Assoc 2000;131:726.
3.   Schantz SP, Yu GP.  Head and neck cancer incidence trends in young Americans, 1973–1997, with a special analysis for tongue cancer.  Arch Otolaryngol Head Neck Surg 2002;128:268-274.
4.   Newland JR, Meiller TF, Wynn RL, Crossley HL.  Oral soft tissue diseases:  A reference manual for diagnosis and management.  Hudson, OH:  Lexi-Comp, Inc.;2002;100.


General Dentistry, September-October 2008 , Volume 56 , Issue 6


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