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Home All issues Volume 31 / No 1 (2025) J Oral Med Oral Surg, 31 1 (2025) 3 Full HTML
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J Oral Med Oral Surg
Volume 31, Number 1, 2025
Article Number 3
Number of page(s) 10
DOI https://doi.org/10.1051/mbcb/2025005
Published online 18 February 2025

© The authors, 2025

Licence Creative CommonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction

Oral Squamous Cell Carcinoma (OSCC): some facts and figures

The Global Cancer Observatory (GCO), which records data on malignant neoplasms form all around the world, accounts 389,485 new cases of oral squamous cell carcinoma (OSCC) worldwide in 2022 [1]. Surgical treatment of OSCC, especially when performed at advanced stages, may result in tissue mutilation and functional impairment of swallowing, speech, and taste; quality of life of patients may thus be substantially reduced [2,3].

OSCC may have heterogeneous clinical presentation: from a white patch to a red patch, to a mixed white/red area, to an ulcer or a lump [4,5]. Early-stage lesions are often completely symptom-less [6]; as they progress, they can cause discomfort due to ulceration, causing pain and functional disfunction and may spread to regional lymph nodes [7]. OSCC is most common at the posterior lateral border of the tongue, accounting for the highest estimated incidence with 50% of all OSCC cases [8]. OSCC metastases predominantly affect ipsilateral lymph nodes of the neck; more rarely, they may also be found at contralateral lymph nodes or bilaterally. When it spreads outside of the lymphatic network of the neck, OSCC metastases may be found in lungs, bones, and the liver [9].

Patients affected by oral potentially malignant disorders (OPMDs) have an increased risk to develop OSCC. OPMDs include oral leukoplakia (OL), oral erythroplakia (OE), oral submucosal fibrosis (OSMF), and oral lichen planus (OLP) [10].

Treatment of OPMDs is still under debate. There are no standard approaches for treating OL [11,12]. Some suggest, according to presence/absence of dysplasia, that OL should be treated surgically by excision. Nevertheless, literature reveals that surgery may not eliminate the risk of developing OSCC in OL patients [13]. For these reasons, sometimes clinicians prefer a “wait and see” approach, especially in case of wide/recurrent lesions. Similarly, OLP/OLL require continuous follow-up, as it is treated with symptomatic care as opposed to curative care [14].

As a direct consequence of the “wait and see” policy, whether it has been chosen in line with the disease characteristics (OLP/OLL) or it was the clinician's choice, OPMD patients have to undergo frequent clinical follow-up [15,16], periodically undergoing single or multiple biopsies, which also poses the conundrum to the clinician of which site to choose in case of extended/multiple lesions. Selecting an area to perform a biopsy far away from a spot which has already undergone malignant transformation leads to misdiagnosis.

Despite what has been seen for many other cancers such as breast or colon, the OSCC/OPMD situation is thus practically unchanged from the past several decades, with unaltered mortality and survival rates and high morbidity associated with available therapeutic strategies [17].

As advanced therapies fail to effectively reduce the disease burden, surveillance and early detection make up the foundation for reducing the incidence of advanced cancer and possibly reduce mortality [18]. In the past years, in addition to conventional visual and tactile examination scientific literature indicates how non-invasive imaging techniques may represent a key strategy and a valid clinical aid for the early detection of oral cancer [19]. These adjunctive tests include vital staining, oral cytology, light-based examination, alone or in combination [20,21]. Of these tests we propose to review the utility of Narrow Band Imaging as an adjunctive technique in investigating OPMDs and early oral cancer.

Narrow Band Imaging (NBI); instruments, the technique and application

Narrow band imaging (NBI) is a non-invasive fibroscopic technique which uses blue and green light with respective wavelengths of 415 and 540 nm. It consists of a regular fiberscope, by which light emission can be modulated from white light (which comprises every wave length) to one narrowed to 415/540 nm. Those specific wavelengths of light penetrate the epithelial layer and are absorbed by the capillaries in the submucosa immediately underneath the surface epithelium. After filtering the scattered light, the machine, connected to magnifying monitors, highlights the intrapapillary capillary loops (IPCL) of the most superficial layers of connective tissue. When compared to white light, NBI contrasts blood vessels significantly, providing distinct images of IPCLs [22]. Interpretation of NBI images is operator dependent. The most used classification for NBI is based on the 4-pattern system described by Takano et al [23]:

  • IPCL Pattern I appears with both waved arms together, as a waved line;

  • IPCL Pattern II has a similar shape to type I, but their caliber is notably increased compared with others far from the lesion;

  • IPCL Pattern III shows elongation, dilation and twisting vessels;

  • IPCL Pattern IV shows large vessels with no loops, with destruction of physiological patterns and arborization.

IPCL I and IPCL II are usually associated with normal mucosa. IPCL III and IPCL IV are associated with dysplasia and malignant transformation [23].

Among the different classifications, the Takano classification is the one which has been proved most reliable [24,25].

A recent systematic review of systematic reviews, found out that NBI was the only clinical visual aid for which there is enough evidence for recommendation as a diagnostic adjunctive tool for detecting OSCC or the malignant transformation of OPMD. NBI fibroscopy can be considered as a guide for diagnosis, including tissue biopsy − which still is the gold standard [26].

Taken into account the criticisms on current applications which contribute to diagnostic delays of OSCC, Narrow Band Imaging (NBI) fibroscopy has shown itself capable of differentiating healthy from dysplastic/neoplastic oral epithelium and has a great potential as an adjunctive tool for clinicians in guiding the diagnosis of OSCC.

We have thus performed a review of the published scientific literature on the use of NBI in the oral cavity. After retrieving available evidence on NBI effectiveness, we present some retrospectively selected clinical cases which demonstrate the utility of this optical system in early diagnosis of OSCC. We outline a “step by step” guide to the clinicians who wishes to explore using this diagnostic tool.

Materials and methods

Review of the published literature

A web search was performed on Web of Science, MEDLINE (via PUBMED) and Scopus. Terms which would have been useful for research were checked on the Medical Subject Headings (MeSH) of the National Library of Medicine −NLM (https://www.ncbi.nlm.nih.gov/mesh/).

Then to maximize sensitivity, a combination of related free terms combined with MeSH terms were used to fill the search query:

“(mouth) OR (oral) and ((Narrow Band Imaging) OR (NBI) OR (Band Imaging, Narrow) OR (Band Imagings, Narrow) OR (Imaging, Narrow Band) OR (Imagings, Narrow Band) OR (Narrow Band Imagings) OR (Narrowband Imaging) OR (Imaging, Narrowband) OR (Imagings, Narrowband) OR (Narrowband Imagings))”.

Regarding search dates, no lower date limit was set, and the upper date limit was September 2024.

Duplicates and papers not written in English were excluded. Through title and abstract analyses, the publications were initially screened. Review articles/commentaries/letters to the editors were excluded. Articles on clinical research and cases series/reports on the use of NBI in the oral cavity were selected. After full text analysis, pertinence of the topic was re-evaluated and only articles which used the 2010 Takano [23] classification for NBI interpretation were finally included, as it has been proved to be the most effective one for the oral cavity. The study selection is illustrated in Figure 1.

thumbnail Fig. 1

The flow diagram depicts the results of the literature search, study identification, and selection process.

Case series

After retrieving available evidence, we retrospectively selected three cases from our stored archives, in order to give to the readers a practical guide on how to use NBI in the oral cavity.

Results

Review of the published literature

The web search was performed on 22th October, 2024 and produced 652 results. After exclusion of duplicates and articles which were not written in English, the results were narrowed to 217 results. Then, through title and abstract analyses, off-topic, reviews were excluded, we selected 49 articles on the use of NBI in the oral cavity. After full text analysis, pertinent articles of clinical research which used the 2010 Takano classification [23] we included a total of 27 selected articles; the data are summarized in Table I.

From 2011 to 2024, 27 publications were found reporting the clinical research conducted using NBI in the oral cavity. Some of them were on oral cavity and oropharynx; for the purpose of this review, only the data related to the oral cavity were considered. They were all retrospective or prospective, non-randomized, non-case-controlled studies, leading to moderate scientific evidence.

Initially published studies [27–30] focused on the reliability of the technique in detecting OSCC. A high value of sensitivity and specificity (both around or higher than 90%) were found, with a good correlation between high grade IPCL patterns (III or IV) and OSCC/High Grade Dysplasia (HGD). Subsequent studies confirmed NBI ability to differentiate between OSCC and OPMD [35,47,48,50,51,54], with higher specificity and sensitivity than white light [44,47,51]. Four studies focused on NBI and OLP/OLL, suggesting that NBI may detect chronic lesions which may undergo malignant transformation [42,43,45,46].

From 2015, several studies focused on NBI pre/peri-operative evaluation of surgical margins [31,34–41,48,52,53]. Interestingly, in this group of studies we found several that did not find any benefit from the NBI use [52,53]. For example, in a prospective study of 34 patients, Nilsson et al [53] reported that the delineation of mucosal tumor borders in oral cancers by NBI was not better than that by white light examination. On the other hand, 10 other studies [31,34–41,48] − which were published by 2 research groups - found a significant benefit from NBI surgical margins evaluation, both in terms of confirming disease-free margins and in long-term disease-free survival.

Some papers underlined that NBI interpretation may require a long learning curve, as it is influenced by operator's experience, variations observed in epithelial thickness of the oral mucosa in different anatomical subsites of the oral cavity and the variations observed in the capillary structure of OLP/OLL [38,42,47,51,52].

Table I

Included papers in chronological order.

Clinical cases

Clinical case I

G.P., A 42-year-old male was diagnosed with oral lichenoid lesions (OLL) when he was 27 yr old. He developed a micro invasive OSCC and had two surgeries within the last 5 yr. NBI examination of the whole mouth was performed during a follow up visit and the remaining lichenoid lesions showed IPCL patterns II and III. A biopsy was performed that confirmed OLL with no evidence of carcinoma. He is on a regular 6 monthly follow up regime and at each visit COE supported by NBI examination is undertaken. In Figure 2, we show this clinical example of an OLL lesion that demonstrates IPCL patterns II and III by NBI examination.

thumbnail Fig. 2

The appearance of an OLL lesion showing IPCL patterns II and III (graded by Takano et al system).
thumbnail Fig. 3

White light appearances of an OL of buccal mucosa (A), NBI appearance (B), NBI patterns detail (C) showing pattern IVJ/K according to Xu et al 2024 [57]. OSCC In Situ was found.
thumbnail Fig. 4

Post-surgical scar after incomplete OSCC excision, showing IPCL pattern IV according to Takano et al. 2010 [23].

Clinical case 2

F.D.F.R., a 78-year-old female was referred to our center for an OL. She denied symptoms, comorbidities and previously diagnosed OPMDs. On clinical examination, she had a homogenous leukoplakia of the buccal mucosa of the cheek, of approximately 1.5 cm. At the NBI fibroscopy (Fig. 3), the lesion showed pattern IV (J-K according to Xu 2024 classification). An incisional biopsy performed at most significant NBI spot revealed OSCC Cis. She then underwent Oncological Multidisciplinary Team (OMT) evaluation with Neck Node US and Head & Neck CT Scan, both negative. The patient was thus classified as TisN0M0 and wide excision of the leukoplakia was thus performed after OMT indication. She is now undergoing follow-up, and is free of disease.

Clinical case III

M.B., A 57-year-old male was referred to our center for follow-up, following an excisional biopsy of a small ulcer on the right posterior margin of the tongue. Histopathology revealed surgical margins as “close”. He attended with a post-surgical scar in good condition; he had no clinically recognizable oral lesions. At NBI fibroscopy (Fig. 4), the post-surgical site revealed an anomalous IPCL vascularization, with anomalous arborization and loss of physiological patterns of appearance of capillaries. He was thus classified as IPCL IV and a subsequent biopsy revealed a recurrent OSCC at this site. The patient underwent routine staging, was classified as T1N0M0 and was seen by Oncological Multidisciplinary Team (OMT) for further evaluation and for management of his OSCC recurrence. The case illustrates that NBI can detect a recurrent OSCC in the absence of clear clinical signs of a malignancy in an area of scarring following previous surgery.

Discussion: a guide to the clinician

In over 12 yr of published literature on the use of NBI in oral cavity, we found there was a general consensus of a good correlation with of high grade IPCL patterns and HGD/OSCC. Whether it is in predicting high grade dysplasia or OSCC presence in a patch of oral leukoplakia [33] or distinguishing among non-healing oral ulcers [34], studies indicate that OPMD examination could benefit from NBI examination [35]. In particular, NBI use for clinical oral examination was not performing as an alternative to the gold standard biopsy, but as a valid aid tool. Similarly, patients with chronic lesions from OLP/OLL may as well benefit from NBI-assisted follow-up [30,42,43,45,46,51] in terms of anticipating detection of malignant transformation.

NBI fibroscope is an expensive machine, the interpretation of images needs considerable calibration through an experienced instructor and may have a long learning curve [38,42,47]. Its effectiveness in primary care should be carefully evaluated before embarking on its use. Fibroscopy may add some additional chairside time to the patient's visit, as every lesion needs to be carefully examined, keeping the probe as close to the mucosa without losing the focus. Furthermore, especially for patients with a history of OPMD/OSCC, a full mouth NBI fibroscopy is strongly advised.

As many primary research publications and systematic reviews suggest [21,26,28–30,42,43,45,46,50,54–56], NBI-aided biopsy may become standard of care in the near future, both during first diagnosis and follow-up. Recently, a new classification has been proposed [57] for improved interpretation of IPCL patterns. This classification represents an evolution of the four-grades pattern IPCL system by Takano [23], providing a better description of IPCLs visualized through new generation high definition fibroscopic magnification systems.

So, if a clinician wants to use NBI, the first thing is to understand the cohort of patients who would benefit from its use. It is not likely that general dental practitioners may find much use for it, but Secondary Care centers may on the other hand benefit by performing NBI fibroscopy. NBI may be useful when help is needed in choosing when or selecting the optimal site to perform a diagnostic biopsy, both for first diagnosis or during follow-up, of OPMD lesions and OSCC.

When the clinicians find themselves in a clinical situation whether to biopsy or not to diagnose an oral lesion, or when choosing the site of biopsy in case of an extended/multifocal lesion, or doing periodical follow-up examinations of patients with chronic/recurrent lesions, NBI may actively help the decision tree.

We note there is no high quality scientific evidence from published studies indicating that NBI performs better when compared to standard clinical oral examination. Yet, a recent paper found moderate evidence through performing a systematic review of systematic reviews [26] that NBI may be a useful tool in guiding to undertake a biopsy.

In particular, NBI showed itself to be able to differentiate between OSCC and chronic oral lesions such as OLP/OLL [30,42,43,45,46,51] and in general from OPMDs. There is no evidence in the literature to recommend its use for screening for oral cancer in the general population [26].

Conclusion

NBI has shown incredibly promising results, possibly being a device able to detect OSCC at an early stage in patients at high risk of developing OSCC. NBI is a non-invasive fibroscopy technique that could thus be of great assistance in clinical practice for specialists who routinely deal with follow-up of susceptible patients such as those with a history of OPMD/OSCC, with or without clinically visible lesions.

Our review also indicated that almost every published study on the topic is retrospective; rigorous prospective approaches with the inclusion of the wider disease spectrum is currently required for giving definitive answers about NBI application for early diagnosis of OSCC in high-risk patients.

Funding

The authors declare they have received no funding for performing this review.

Conflicts of interest

The authors declare they have no conflict of interest in performing this review.

Data availability statement

The data that support the findings of this study are available from the corresponding author, AG, upon reasonable request.

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Cite this article as: Guida A, Perri F, Annunziata M., Monteiro L, Warnakulasuriya S. 2025. A practical guide to the use of Narrow Band Imaging (NBI) in the early detection of oral cancer: case series and review of the literature. J Oral Med Oral Surg. 31: 3. https://doi.org/10.1051/mbcb/2025005

All Tables

Table I

Included papers in chronological order.

In the text

All Figures

thumbnail Fig. 1

The flow diagram depicts the results of the literature search, study identification, and selection process.
In the text
thumbnail Fig. 2

The appearance of an OLL lesion showing IPCL patterns II and III (graded by Takano et al system).
In the text
thumbnail Fig. 3

White light appearances of an OL of buccal mucosa (A), NBI appearance (B), NBI patterns detail (C) showing pattern IVJ/K according to Xu et al 2024 [57]. OSCC In Situ was found.
In the text
thumbnail Fig. 4

Post-surgical scar after incomplete OSCC excision, showing IPCL pattern IV according to Takano et al. 2010 [23].
In the text

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