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Original Article

Recent advances in diagnostic oral medicine

Venkatesh G. Naikmasur, Atul P. Sattur, Sunil Mutalik, Arpita R. Thakur
Department of Oral Medicine and Radiology, S. D. M. College of Dental Sciences and Hospital, Dharwad, Karnataka, India

ABSTRACT
Oral medicine is an area of dentistry which is constantly changing. Over the past several years Oral medicine has expanded in
both scope and complexity. Oral medicine involves the diagnosis and management of complex diagnostic and medical disorders
affecting the mouth and jaws. Current decade has witnessed enormous advances in the diagnostic oral medicine, which have moved
from the laboratory to the dental clinics and hospitals. It is important that these advances do not remain as domain of the specialists
in this field. Every general dental practitioner should be aware of recent advances in diagnostic oral medicine in order to provide
a high level of care. This paper discusses the recent technological advances in the field of oral medicine that have made an impact
on clinical dental practice.

Key words: Chemiluminescence, diagnostic AIDS, oral CDX, oral diagnosis, oral medicine, spectroscopy, recent advances,
vital staining
DOI: 10.4103/0972-1363.58748

INTRODUCTION carcinoma of head and neck has remained approximately

Oral medicine with respect to diagnostic decision making
has seen remarkable advances over the years. Technical
advances from biochemistry, immunology, histopathology,
molecular biology, and optical physics have moved from
laboratories into dental clinics and have combined together
to radically change the way diagnosis is arrived at or
confirmed. Advances have come about both through a
greater degree of research activity in this field, and as a result
of the application of recent technical developments which
have permitted the investigation of questions which could
not previously be approached. Radiology has participated
in the recent trend toward computerized management in
health service and has responded to the demand for cost-
efficient and rapid communication between department of
radiology and other dental specialties. But, with these recent
technical innovations, the art of diagnosis has become much
more of a science and the attitude of clinician has changed
from clinicocentric to technocentric.
Advances in diagnostic oral medicine are aimed at reducing
the morbidity and mortality associated with oral diseases.
For example, despite numerous advances in treatment,
the 5-year survival rate of patients with squamous cell
50% for the last 50 years.[1] Based on the increasing
incidence of head and neck cancers, problems associated
with late diagnosis, and the public health dilemma they
represent, it seems prudent to enact screening protocols
to check at-risk people. Early diagnosis would allow for
conservative therapeutic approaches with a brief recovery
and a more favorable prognosis. This basic concept
should be applied to all diseases affecting the oral cavity.
Diagnosis should not be done at the first sign or symptom
of a problem but on very routine and very frequent basis.
Patients, at such screening visits, who show any indication of
developing pathology should be more intensively examined
and treated.
Changes are inevitable, even in the science foundational
to the clinical practice of dentistry. Increased diversity and
sophistication are developing in the areas of molecular
biology, basic science, and social sciences. These will
transform our traditional approaches to oral and dental
disease management. In this paper, we shall see the recent
technological advances in the field of oral medicine that
may make an impact on clinical dental practice.
ADVANCES IN EARLY DETECTION OF CANCER

Precancers and early stage oral cancers may not be

Address for correspondence: Dr. Venkatesh G. Naikmasur, Department
of Oral Medicine and Radiology, S.D.M. College of Dental Sciences and adequately identified by visual inspection alone and may
Hospital, Dharwad, Karnataka - 580 009, India. E-mail: vnmasur@gmail.com be easily overlooked and neglected, even by highly trained

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Naikmasur, et al.: Diagnostic oral medicine

professionals.[2] Clinical diagnostic tools available for the
early detection of oral cancer include tolonium chloride or
toluidine blue dye, Lugol’s iodine, oral brush biopsy kits,
photodiagnosis, and chemiluminescence. These systems
will be discussed in the following section.
Vital staining
Vital staining of the oral epithelium has been suggested as a
means of surveillance in patients who are at risk of developing
oral cancer and for those who have had a confirmed neoplasm
in other parts of the aerodigestive tract. In vivo vital staining
has been used extensively in gynecology for the detection of
malignant change of the cervix via colposcopy.[3] Toluidine
blue staining is considered to be a sensitive adjunct tool for the
identification of early oral squamous cell carcinoma (OSCC)
and high-grade dysplasia.[4] Toluidine blue is an acidophilic
metachromatic dye of thaizine group that selectively stains
acidic tissue components such as DNA and RNA.[5] Its use
in vivo is based on the fact that dysplastic and anaplastic cells
contain quantitatively more nucleic acid than normal cells.
Toluidine blue stains mainly two types of lesions: Squamous
cell carcinoma and inflamed traumatic tissue. Patients with a
positive test are retested in 10-14 days, while a second positive
test makes biopsy mandatory. Senstivity of this technique
ranges from 0.78 to 1.0 while specificity yields to 0.31-1.0.[1]
A combined use of toluidine blue and Lugol’s iodine has
been tried, as toluidine blue stains abnormal epithelium
whereas Lugol’s solution binds to glycogen present in
normal epithelium.[3] One interesting screening method
is the application of 3-5% acetic acid, which has been
used for cervical cancer screening. [6] The sensitivity,
specificity, and accuracy of using acetic acid for oral
cancer examination were reported to be 83.33%, 84.21%,
and 83.64%, respectively.[6] Methylene blue [Figure 1],
which has been used to detect gastric, prostate, and
bladder cancers, may be used in the detection of oral
lesions.[7] The sensitivity for use in oral cavity was 90%,
the specificity 69%, positive predictive value 74%, and
negative predictive value 87%.[7]
Chemiluminescent illumination
The term “chemiluminescence” refers to the emission of
light from a chemical reaction.[8] In this system, a nontoxic
blue-white chemiluminescent light is shone into mouth and
tissue reflectance is observed. Under this light, dysplastic
tissues with enlarged nuclei, highlighted by dehydration
with acetic acid, appear “aceto white.”[9] The Vizilite
chemiluminiscent light stick comprises an outer flexible
plastic capsule containing aspirin or acetyl salicylic acid and
an inner fragile glass vial containing hydrogen peroxide. The
activation of the capsule is achieved by flexing it, wherein,
the inner fragile glass vial ruptures releasing the hydrogen
peroxide. The chemicals react to produce light of blue-white
color (430-580 nm) which lasts for 10 min.[8] Another device
that works on the principle of chemiluminescence is the
Microlux DL unit, which offers a reusable battery-powered
light source.[1] The accuracy of the technique to detect oral
cancer and potentially malignant epithelial lesions is 80.6%
as compared to 64.5% of toluidine blue.[8]
Oral brush biopsy
Oral CDx is a highly specialized computer-assisted analysis
of oral brush biopsy performed in a dental office.[2] It is
a rapidly conducted chair side procedure that results in
minimal bleeding, requires no topical or local anesthetic,
and results in a collection of a complete transepithelial tissue
sample. Oral CDx kits supplied to investigators consist of
an oral brush biopsy instrument, a precoded glass slide
and matching coded test requisition form, an alcohol/
polyethylene glycol fixative pouch, and a preaddressed
container to submit the contents. In addition to precancer
and cancer detection, it can provide morphologic evidence
of a variety of benign oral processes like candidiasis,
herpes infection, pernicious anemia, radiation effects, and
pemphigus. However, oral CDx does not substitute for a

Figure 1: Vital staining with methylene blue. (a) Clinical view of the potentially malignant lesion on right buccal mucosa, (b) Application of methylene
blue on the lesion, (c) Methylene blue retention in the lesion subsequently diagnosed as early invasion squamous cell carcinoma

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Naikmasur, et al.: Diagnostic oral medicine
scalpel biopsy; rather, it identifies oral lesions that require
a histologic evaluation. The specificity rates are reported
to be 100% for “positive” oral CDx results and 92.9% for
“atypical” oral CDx results. The sensitivity rate for oral CDx
is also reported as 100%.[2]
The oral brush biopsy without computer-assisted analysis
[Figure 2] has been tried for the evaluation of oral lesions
in resource-challenged settings to rule out dysplasia and
carcinoma. The toothbrush biopsy with manual analysis
had marginally lower sensitivity and specificity than the
commercially available oral brush biopsy with computer-
assisted analysis.[10]
Photodiagnosis
Optical spectroscopy provides tissue diagnosis in real time,
noninvasively and in situ. This relies on the fact that the optical
spectrum derived from any tissue will contain information
about the histological and biochemical makeup of that tissue.
Photodiagnosis is used for the detection of dysplasia and
malignancy, in performing guided biopsies, monitoring of
hemoglobin tissue perforation in free flap and therapeutic
drug levels during chemotherapy and photodynamic therapy,
assessment of the surgical margins, and plays a role in sentinel
node biopsy.[11] Three main techniques currently utilized in
the detection of oral dysplasia and malignancies are
• Flourescence spectroscopy: Flourescence, which can
be autofluorescence or a laser-induced phenomenon,
occurs due to the presence of flourophores like NADPH,
collagen, elastin, and cofactors. A significant increase
in red/green fluorescence is an accurate predictor of
dysplasia and malignancy.[11] VELscope [Figure 3] is
a portable device based on narrow-emission tissue
fluorescence which provides light in the range of
400-460 nm. Under the intense blue light, normal
mucosa emits a pale green autoflourescence while the
suspicious tissue appears dark.[1]
• Elastic scattering spectroscopy (ESS): It generates a
wavelength-dependent spectrum that reflects both
scattering and absorptive properties of the tissue. ESS
Figure 2: Modified oral brush biopsy (without computer-assisted analysis), (a) Clinical view of a potentially malignant lesion in the right
retrocommisural area, (b) Commercially available nylon toothbrush repeatedly brushed in one direction to obtain transepithelial biopsy,
(c) Photomicrograph of cytosmear (⫻40 magnification) showing dysplastic cells
Journal of Indian Academy of Oral Medicine and Radiology / Jul-Sep 2009 / Volume 21 / Issue 3
is sensitive for nuclear size, chromatin content, nuclear-
cytoplasmic ratio, and cellular crowding, which are all
criteria for establishing malignancy.[11]
• Raman spectroscopy: It is a form of elastic scattering and
is generated by a shift in the frequency of the incident
excitation light. It is most accurate technique but signals
are weak.[11]
• Trimodal spectroscopy: It is a combination of all the
above-mentioned three to increase the accuracy of the
technique.[11]
Two photosensitizers which are known to have a high
specificity and sensitivity for tumor diagnosis are mTHPC
(Foscan) and ␦-amino levulinic acid (levulan). An increased
uptake of these photosensitizers is due to the limited ability
of the malignant tissue to metabolize iron, thus resulting in
increased intracellular protoporphyrin IX.[12]
ADVANCED MEASURES TO DETECT INCIPIENT
DENTAL CARIES
In the research arena, recording carious lesions only at the
cavitation level is no longer acceptable. The ideal caries
detection method should capture the whole continuum
of the caries process, from the earliest stages through the
cavitation stage. The real challenge is to detect the lesional
activity at a threshold that leads to an appropriate early
intervention with prevention and not just treatment.
Of all the technologically advanced measures to detect
caries, fluorescence and transillumination have the most
potential. Two methods based on the fluorescence of
the organic components of teeth are quantitative laser
or light florescence (QLF) which uses an arc lamp with a
290- to 450-nm wavelength, and DIAGNOdent which uses
infrared light of 655-nm wavelength. A new approach in
this field is a fluorescence spectrophotometer, which uses
several wavelengths. Also, recent developments in the
DIAGNOdent technique have led to the introduction of a
hand-held laser caries detection aid, DIAGNOdent pen. It
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Naikmasur, et al.: Diagnostic oral medicine
Figure 3: Velscope—A portable device based on narrow-emission
tissue fluorescence (400-460 nm)
uses a probe with a wedge-shaped, solid, single sapphire
fiber tip that is designed specifically to fit the interproximal
space between posterior teeth.[13]
Methods based on transillumination are FOTI (fiber optic
transillumination) and direct imaging fiber optic
transillumination (DIFOTI). FOTI allows for the detection
of a carious lesion because of the changes in the scattering
and absorption of high-intensity light photons resulting
from a local decrease in transillumination owing to the
characteristics of the carious lesion. Enamel lesions
appear as gray shadows, and dentinal lesions appear as
orange-brown or bluish shadows. DIFOTI is a more recent
development combining FOTI with a charge-coupled
device digital intraoral camera.[13]
ADVANCED CLINICAL DIAGNOSIS OF PERIODONTAL
DISEASE
Over the years, different periodontal probe prototypes,
such as the Florida probe system have been developed to
overcome limitations of conventional probes. The latest
of them being Florida PASHA probes.[14] Also, ultrasonic
periodontal probes have been developed based on a
noninvasive ultrasonic technique to detect, image, and map
the upper boundary of the periodontal ligament and its
variation over time as an indicator of periodontal disease.[15]
Recently, radionuclides, like technetium 99m-tin-
diphosphonate, have been tried as an indicator of active
alveolar bone loss in the diagnosis of a periodontal disease
activity.[16]
Conventional clinical and radiographical methods of
periodontal diagnosis are only capable of retrospective
diagnosis of attachment and bone loss; these are unable
102 Journal of Indian Academy of Oral Medicine and Radiology / Jul-Sep 2009 / Volume 21 / Issue 3
to either detect or predict the periodontal disease activity.
Therefore, potential biomarkers of the periodontal disease
activity are being assessed, such as
• Subgingivalbacteria and their products
• Inflammatory and immune products
• Enzymes released from inflammatory cells and dead cells
• Connective tissue degradation products.[17]
Also, host inflammatory products synthesized by the
periodontium appear within the gingival crevicular fluid
(GCF) and thereby offer a rich potential for the use of GCF
to obtain diagnostic information regarding periodontal
health or disease status.[18]
Thus, in periodontal diagnostics, it is anticipated that these
new tools will enable subclinical disease to be detected or
perhaps even future disease activity to be predicted.
Sialoendoscopy
Sialoendoscopy is a promising new method for use in the
diagnosis, treatment, and postoperative management of
sialolithiasis, sialadenitis, and other obstructive salivary
gland diseases. It permits the surgeon to observe and diagnose
intraductal and sometimes intraglandular pathologies,
through insertions of a 1-mm-diameter endoscope (mostly
semirigid type) through the dilated duct of any major salivary
gland. It is an outpatient procedure, using local anesthetic,
and does not have major complications.[19] With the use
of specially designed mini forceps, graspers, baskets, and
balloon catheters, it is possible to remove calculi located in
deeper portions. It has unfolded the microanatomy of the
inner portion of the duct, revealing strictures, the opening of
the sublingual gland, and secondary channels.[20]
Oral fluid testing
Saliva, the most accessible and noninvasive biofluid of our
body, harbors a wide spectrum of biological markers for
clinical diagnostic applications. The molecular composition
of saliva reflects tissue fluid levels of therapeutic, hormonal,
immunological, or toxicological molecules. In addition,
markers for diseases (e.g., infectious and neoplastic) can be
present. Consequently, these fluids provide sources for the
assessment and monitoring of systemic health and disease
states, exposure to environmental and job-related toxins,
and the use of abusive or therapeutic drugs [Figure 4]. While
proteomic constituents were a logical first choice as salivary
diagnostic analytes, genomic targets have emerged as
highly informative and discriminatory.[21] The utilization of
emerging technologies such as micro- and nanofabrication,
miniaturized analytical systems, microfluidics, microsensors,
and high-density arrays of DNA will facilitate the analysis of
oral fluid-derived components (cells, DNA/RNA, proteins,
hormones, drugs, metabolic products). [22] Circulatory
epithelial tumor markers such as Cyfra 21-1, tissue
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Naikmasur, et al.: Diagnostic oral medicine
Figure 4: Oral fluid testing - UV-visible light spectrophotometer used
for saliva testing
polypeptide antigen, and CA125 are being investigated in
saliva of OSCC patients.[23]
Nanodiagnostics
Nanodiagnostics, defined as the use of nanotechnology for
clinical diagnostic purposes, was developed to meet the
demands of clinical diagnostics for increased sensitivity and
earlier detection of disease. The use of nanotechnologies
for diagnostic applications shows great promise to meet the
rigorous demands of the clinical laboratory for sensitivity
and cost-effectiveness. New nanodiagnostic tools include
quantum dots (QDs), gold nanoparticles, and cantilevers.
QDs, which are the most promising nanostructures for
diagnostic applications, are semiconductor nanocrystals
characterized by high photostability, single-wavelength
excitation, and size-tunable emission. QDs and magnetic
nanoparticles can be used for barcoding of specific analytes.
Gold and magnetic nanoparticles are key components
of the bio-barcode assay, which has been proposed as
a future alternative to polymerase chain reaction (PCR).
The potential diagnostic uses of QDs are numerous,
with the most promising applications being in the areas
of tumor detection, tissue imaging, intracellular imaging,
immunohistochemistry, infectious agent detection,
multiplexed diagnostics, and fluoroimmunoassays.
Nanodiagnostics promise increased sensitivity, multiplexing
capabilities, and reduced cost for many diagnostic
applications as well as intracellular imaging.[24]
CONCLUSION
We are in the era of information overload. The fields of
medicine and oral medicine are changing and we have
come a long way. There is still much to be done as far as
patient management and accuracy of diagnostic methods
is concerned, which will enable the society as a whole to
be more productive and healthier.
Journal of Indian Academy of Oral Medicine and Radiology / Jul-Sep 2009 / Volume 21 / Issue 3
ACKNOWLEDGMENTS
We thank Dr. Lijoy Abraham, Dr. Gokul S, and Dr. Medha
Babshet for providing photographs for the manuscript.
Photographs of Velscope are courtesy from Confident India
Private Limited.
REFERENCES
1. Mark WL, John RK, Theodore K, Paul MS. Critical evaluation of
diagnostic aids for the detection of oral cancer. Oral Oncology
2008;44:10-22.
2. Scuibba JJ. Improving detection of precancerous and canerous oral
lesions. JADA 1999;130:1445-57.
3. Epstein JB, Scully C, Spinelli JJ. Toluidine blue and Lugol’s iodine
application in the assessment of oral malignant disease and lesions
at risk of malignancy. J Oral Path Med 1992;21:160-3.
4. Zhang L, Williams M, Poh CF, Laronde D, Epstein JB, Durham S, et al.
Toluidine blue staining identifies high-risk primary oral premalignant
lesions with poor outcome. Cancer Res 2005;65:8017-21.
5. 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 Oral Radiol Endod 1998;85:444-6.
6. Bhalang K, Suesuwan A, Dhanuthai K, Sannikorn P, Luangjarmekorn L,
Swasdison S. The application of acetic acid in the detection of oral
squamous cell carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2008;106:371-6.
7. Chen YW, Lin JS, Fong JH, Wang IK, Chou SJ, Wu CH, et al.
Use of methylene blue as a diagnostic aid in early detection of
oral cancer and precancerous lesions. Br J Oral Maxillofac Surg
2007;45:590-1.
8. 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 2005;34:521-7.
9. Satoskar S, Dinkar A. Diagnostic aids in early cancer detection.
JIAOMR 2006;18:82-3.
10. Mehrotra R, Singh MK, Pandya S, Singh M. The use of an oral
brush biopsy without computer-assisted analysis in the evaluation
of oral lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2008;106:246-53.
11. Swinson B, Jerjes W, El-Maaytah M, Norris P, Hopperl C. Optical
techniques in diagnosis of head and neck malignancy. Oral Oncology
2006;42:221-8.
12. Konopka K, Goslinski T. Photodynamic therapy in dentistry.J Dent Res
2007;86:694-707.
13. Zandona AF, Zero DT. Diagnostic tools for early caries detection.
JADA 2006;137:1675-84.
14. Sanz M, Newman MG, Quirynen M. Advanced diagnostic techniques.
In: Newman MG, Takei HH, Klokkevold PR, eds. Carranza’s Clinical
Periodontology. ST. Louis: Saunders; 2006. p. 579-98.
15. Hinders M, Companion J. Ultrasonic Periodontal Probe: A painless
way to monitor gum disease, Acoustical society of America, 136th
meeting Lay language papers. Available from: http://www.acoustics.
org/press/136th/hinders.htm. Accessed on 20.6,2008 at 10:30 pm.
16. Hawnaur J. Recent advances in diagnostic radiology. BMJ
1999;319:168-71.
17. Eley BM, Cox SW. Advances in periodontal diagnosis. BDJ
1998;184:109-13.
18. Offenbacher S, Collins JG, Heasman PA. Diagnostic potential of host
response mediators. Adv Dent Res 1993;7:175-81.
19. Nahlieli O, Nakar LH, Nazarian Y, Turner MD. Sailoendoscopy:
A new approach to salivary gland obstructive pathology. JADA
2006;137:1394-400.
20. Hassan O, Gan R. Endoscopy of salivary glands: What have we
learnt, AAOMS 2005;S421:137-8.
21. Bernhard GZ, Noh JP, Wong DT. Genomic targets in saliva. Ann N Y
Acad Sci 2007;1098:184-91.
103
[Downloaded free from http://www.jiaomr.in on Friday, March 17, 2017, IP: 184.56.187.245]

Naikmasur, et al.: Diagnostic oral medicine

22. David TW. Salivary diagnostics powered by nanotechnologies,
proteomics and Genomics. JADA 2006;137:313-32.
23. Nagler R, Bahar G, Shpitzer T, Feinmesser R. Concomitant analysis
salivary tumor markers - A new diagnostic tool for oral cancer.
Clin Cancer Res 2006;12:3979-84.
24. Azzazy HM, Mansour MM, Kazmierczak SC. Nanodiagnostics: A New
Frontier for Clinical Laboratory Medicine. Clin Chem 2006;52:1238-46.
Source of Support: Nil, Conflict of Interest: Nil

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