J Oral Maxillofac Surg

65:424-426, 2007

Efficacy of the ViziLite System in the

Identification of Oral Lesions
Esther S. Oh, DDS, BA,* and Daniel M. Laskin, DDS, MS
Purpose: Early detection of oral cancer is crucial in improving survival rate. To improve early

detection, the use of a dilute acetic acid rinse and observation under a chemiluminescent light (ViziLite;
Zila Pharmaceuticals, Phoenix, AZ) has been recommended. However, to date, the contributions of the
individual components of the system have not been studied. The present study was done to investigate
the efficacy of the individual components of the ViziLite system in providing improved visualization of
early oral mucosal lesions.
Patients and Methods: A total of 100 patients, 39 males and 61 females, age 18 to 93 years (mean age,
44 years), who presented to the Virginia Commonwealth University School of Dentistry for dental
screening were examined. There were 58 Caucasians, 29 African-Americans, 5 Hispanics, 6 Asians, and
2 of mixed ethnicity. Thirty-five patients smoked, 53 used alcohol, and 25 both smoked and drank. After
written consent, the oral cavity was examined under incandescent light for soft tissue abnormalities.
After 1-minute rinse with 1% acetic acid, the mouth was re-examined for additional mucosal abnormalities. Then, the mouth was examined once again using the ViziLite systems chemiluminescent light. Any
lesions detected by these 3 examinations that were clinically undiagnosable were brush biopsied (Oral
CDx) for determination of cellular representation.
Results: In the original examination of the 100 patients, 57 clinically diagnosable benign lesions (eg,
linea alba, leukoedema) and 29 clinically undiagnosable lesions were detected. After the rinse, 6
additional diagnosable lesions (linea alba) and 3 undiagnosable lesions were found. No additional lesions
were detected with the chemiluminescent light. Of the 32 undiagnosable lesions that were brush
biopsied, 2 were positive for atypical cellular characterization and warranted further investigation with
a scalpel biopsy. Neither of these lesions was found to be premalignant or malignant.
Conclusion: Although the acid rinse accentuated some lesions, the overall detection rate was not
significantly improved. The chemiluminescent light produced reflections that made visualization more
difficult and thus was not beneficial.
2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:424-426, 2007
Oral cancer (90% of which are squamous cell carcinomas) ranks as the sixth most common malignancy
worldwide.1 Although the morbidity and mortality

rates for breast, prostate, and cervical cancers have

improved over the past 50 years, those for oral cancer
have not. Some 52% of all patients diagnosed with oral
cancer die within 5 years.2 Yet if diagnosed early,
while still in stage I (T1N0M0) or stage II (T2N0M0),
oral cancer is one of the most curable cancers, with a
survival rate of 80%.3 However, at least one third of
the patients diagnosed with an oral malignancy claim
to have had a conventional oral screening within the
past 3 years.1 This indicates the need for improved
early detection methods.
Existing diagnostic aids to conventional head and
neck examination include exfoliative cytology, toluidine blue staining,4 and Oral CDx brush biopsy.5 The
problem with exfoliative cytology is that it provides
only a surface biopsy and thus fails to include the
deeper cells, where significant changes may be
present. Toluidine blue is a vital nuclear stain that
binds to DNA. Theoretically, dysplastic and malignant
cells have higher nucleic acid content than normal,

*Resident in Oral and Maxillofacial Surgery, School of Dentistry,

University of North Carolina, Chapel Hill, NC.
Professor and Chairman Emeritus, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond, VA.
Dr Oh was funded by an AD Williams research grant from the
School of Dentistry, Virginia Commonwealth University. No funding for this study was provided by Zila Pharmaceuticals or OralScan
Laboratories, Inc.
Address correspondence and reprint requests to Dr Laskin: Department of Oral and Maxillofacial Surgery, School of Dentistry,
Virginia Commonwealth University, PO Box 980566-0566, Richmond, VA 23298-0566; e-mail: dmlaskin@vcu.edu
2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6503-0009$32.00/0
doi:10.1016/j.joms.2006.10.055

424

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OH AND LASKIN

and thus staining of suspicious lesions with this dye

can aid recognition of mucosal changes. In contrast to
exfoliative cytology, brush biopsy provides a complete transepithelial sample. However, although exfoliative cytology and brush biopsy techniques are helpful in establishing a more definitive diagnosis of
already visible lesions, they are of no value in detecting mucosal changes not readily visible to the naked
eye.
In 2002, ViziLite (Zila Pharmaceuticals, Phoenix,
AZ) became the first FDA-approved adjunct technology to conventional head and neck examination for
improving visualization of early lesions. In June 2004,
ViziLite was given a dental reimbursement code by
the Code Revision Committee of the ADA. The
ViziLite system involves an oral rinse with a 1% acetic
acid solution for 1 minute, to remove the glycoprotein barrier and slightly desiccate the oral mucosa. A
diffuse chemiluminescent blue/white light with an
average wavelength of 490 to 510 nm is then activated and used to examine the oral tissues. Normal
cells absorb the light and appear blue, whereas abnormal cells have a higher nuclear/cytoplasmic ratio
and reflect the light to appear more aceto-white,
with brighter, sharper, more distinct margins.1
The literature reporting the efficacy of ViziLite in
the early detection of oral mucosal lesions and the
benefits of this procedure over previous techniques is
limited.1,6,7 Moreover, no data are available showing
the improved visualization of abnormal oral lesions
using the chemiluminescent light versus normal incandescent light after an acetic acid rinse. The purpose of this study was to investigate the efficacy of
the individual components of the ViziLite system (acetic acid and chemiluminescent light), as well as their
combined use, for improved early detection of clinically occult oral mucosal lesions.

Patients and Methods

A total of 100 consecutive patients between ages
18 and 93 years (mean age, 44 years) of any race
and gender who presented for dental screening at
the Virginia Commonwealth University School of
Dentistry were selected for this study. The patient
group comprised 39 males and 61 females, including 58 Caucasians, 29 African-Americans, 5 Hispanics, 6 Asians, and 2 patients of mixed origin. Thirtyfive of the patients actively used tobacco products,
53 regularly drank alcohol, and 25 both smoked and
drank. Twenty-eight of the patients reported a
cheek-biting habit.
Once demographic data were collected and written
consent obtained, each patients oral cavity was visually examined systematically under incandescent light
by a single examiner. Any soft tissue abnormalities

Table 1. RECOGNITION OF INTRAORAL LESIONS

Diagnosable Undiagnosable
Lesions
Lesions
Initial intraoral examination
After acid rinse
After chemiluninescent
light

57
6

29
3

Oh and Laskin. The Vizilite System. J Oral Maxillofac Surg 2007.

were documented by written description and photographs and categorized as diagnosable (ie, clinically
recognizable, such as linea alba or leukoedema) or
undiagnosable (ie, not able to be diagnosed definitively by visual examination alone). After a 1-minute
rinse with 1% acetic acid solution, the patients mouth
was again visually examined for any additional mucosal abnormalities, and these were documented. Finally, the patients oral tissues were examined using
the ViziLite chemiluminescent light. Any undiagnosable lesions detected by the 3 examinations were
sampled with CDx brush biopsy and subsequently
examined microscopically. Brush biopsy results characterized as abnormal were further investigated by
scalpel biopsy for a definitive diagnosis.

Results
A total of 95 lesions were found in 63 of the 100
patients (Table 1). Of these 95 lesions, 63 were classified as clinically diagnosable and 32 were classified
as clinically undiagnosable and subjected to brush
biopsy. Eighty-six of the lesions were found on the
initial clinical examination. Six additional diagnosable
lesions (linea alba) and 3 undiagnosable lesions were
found by examination under incandescent light after
the rinse, but no additional lesions were found after
use of the ViziLite (Table 1). Of the 32 lesions that
were brush biopsied, 2 were deemed atypical and
were scalpel biopsied, but neither proved to be either
premalignant or malignant.

Discussion
Most of the lesions in this study were found during
the initial examination under incandescent light. The
rinse helped detect only 3 new undiagnosable lesions,
which later were found to be benign. No additional
lesions were detected with the Vizilite examination.
In fact, the Vizilite made visualization more difficult,
because it created distracting highlights on the oral
mucosa. Thus, although the acetic acid rinse may
have some value, the chemiluminescent light provides no additional benefit.

426
Until better methods are found, routine oral cancer
screening at each patient visit remains the best
method of detecting early lesions. Despite its limitations, it can still have a dramatic affect on the oral
cancer mortality rate.5 Having knowledge of patients
lifestyle behaviors in terms of alcohol and tobacco use
also can help determine their overall risk for developing oral cancer and guide the need for more frequent
observation as well as counseling on strategies for
avoiding these substances. In high-risk patients, an
acetic acid rinse before oral examination also may be
indicated.
In conclusion, although using an acetic acid rinse
may have some benefit in making mucosal changes
more visible, there appears to be no added benefit
from using a chemiluminescent light rather than incandescent light for subsequent oral examination.

THE VIZILITE SYSTEM

References
1. Huber MA, Bsoul SA, Terzhalmy GT: Acetic acid wash and
chemiluminescent illumination as an adjunct to conventional
oral soft tissue examination for the detection of dysplasia: A
pilot study. Quintessence Int 35:378, 2004
2. Rhosus NL: New initiatives in the diagnosis and prevention of
oral cancer. Northwest Dent 83:21, 2004
3. National Cancer Institute: Cancer Statistics Review, 1973-1990.
Bethesda, MD, US Department of Health and Human Services,
National Institutes of Health, 1993
4. Martin IC, Kerawala CJ, Reed M: The application of toluidine
blue as a diagnostic adjunct in the detection of epithelial dysplasia. Oral Surg Oral Med Oral Pathol Radiol Endod 85:444,
1998
5. Sciubba JJ: Improving the detection of precancerous and cancerous oral lesions. J Am Dent Assoc 15:1445, 1999
6. Kerr AR, Sirois DA: Clinical evaluation of a new adjunctive
technique for oral mucosal examinations: Oral speculoscopy.
Oral Surg Oral Med Oral Pathol Radiol Endod 97:451, 2004
7. Ram S, Siar CH: Chemiluminescence as a diagnostic aid in the
detection of oral cancer and potentially malignant epithelial
lesions. Int J Oral Maxillofac Surg 34:521, 2005