Available Evidence on the Diagnostic Accuracy of Chemiluminescence for Detecting Dysplasia or Malignant Transformation in Oral Potentially Malignant Disorders (OPMDs): A Systematic Review and Meta-Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Ms. Ref. No.  jcm-4036457

Title: What is the diagnostic accuracy of chemiluminescence for detecting 
dysplasia or malignant transformation in oral potentially malignant disorders 
(OPMDs), and which device shows the best performance? Results from systematic 
review and meta-analysis.

This paper should be considerable interest to many of the readers of JCM. Because we think the content of the paper is excellent in terms of analysis and methodology.

However, please be sure to answer the following questions:

1) We agree with the authors that chemiluminescence remains an evolving adjunctive tool for the early detection of oral lesions and cannot replace histopathological examination as the definitive diagnostic modality. However, we find it unfortunate that the Discussion focuses solely on histopathology and does not address the role of oral cytology.

Given that chemiluminescence, cytological examination, and histopathological diagnosis represent distinct yet complementary diagnostic approaches, the Discussion would benefit from a comparative consideration of their respective sensitivity and specificity. In particular, including cytology as an intermediate, minimally invasive diagnostic tool with relatively high sensitivity for epithelial dysplasia would provide a more balanced and comprehensive perspective on early detection strategies.

We therefore recommend that the authors expand the Discussion to address and compare the diagnostic performance (sensitivity and specificity) of chemiluminescence, oral cytology, and histopathological examination, and to clarify how these modalities can be integrated in a stepwise diagnostic algorithm for early detection of oral potentially malignant disorders.

2) The number of included cases is clearly insufficient for a meta-analysis. In our view, a substantially larger sample size is required to ensure the robustness and reliability of the pooled estimates. We recommend increasing the number of cases to at least 300 before drawing definitive conclusions from a meta-analytic approach.

Author Response

We thank the Editor and the Reviewers for their constructive comments, which helped us to improve the manuscript. We have revised the manuscript accordingly, and our point-by-point responses are provided below:

Ms. Ref. No. jcm-4036457
Title: What is the diagnostic accuracy of chemiluminescence for detecting
dysplasia or malignant transformation in oral potentially malignant disorders
(OPMDs), and which device shows the best performance? Results from systematic
review and meta-analysis.
This paper should be considerable interest to many of the readers of JCM. Because we think the content of the paper is
excellent in terms of analysis and methodology.
However, please be sure to answer the following questions:
Comment 1: We agree with the authors that chemiluminescence remains an evolving adjunctive tool for the early
detection of oral lesions and cannot replace histopathological examination as the definitive diagnostic modality.
However, we find it unfortunate that the Discussion focuses solely on histopathology and does not address the role of
oral cytology.
Given that chemiluminescence, cytological examination, and histopathological diagnosis represent distinct yet
complementary diagnostic approaches, the Discussion would benefit from a comparative consideration of their
respective sensitivity and specificity. In particular, including cytology as an intermediate, minimally invasive diagnostic
tool with relatively high sensitivity for epithelial dysplasia would provide a more balanced and comprehensive
perspective on early detection strategies.
We therefore recommend that the authors expand the Discussion to address and compare the diagnostic performance
(sensitivity and specificity) of chemiluminescence, oral cytology, and histopathological examination, and to clarify how
these modalities can be integrated in a stepwise diagnostic algorithm for early detection of oral potentially malignant
disorders.
Response: We thank the Reviewer for this valuable and constructive comment. In response, we have expanded the
Discussion section to provide a comparative consideration of the diagnostic performance of chemiluminescence, oral
cytology, and histopathological examination in terms of sensitivity and specificity. Specifically, we clarified the
complementary roles of these modalities, emphasizing histopathology as the gold standard for definitive diagnosis,
chemiluminescence as a non-invasive adjunctive tool with high sensitivity but limited specificity, and oral cytology as
an intermediate, minimally invasive diagnostic approach with relatively high sensitivity and generally higher specificity
compared with chemiluminescence.Moreover, we proposed a stepwise diagnostic algorithm integrating these
modalities, outlining their sequential application from initial clinical assessment to definitive histopathological
confirmation. We believe that this addition enhances the clinical relevance of the Discussion and provides a more
comprehensive framework for early detection and management of oral potentially malignant disorders.
Text change: Collectively, these results suggest that chemiluminescence can be considered an auxiliary method, but not
a standalone one, in diagnosing oral lesions. In this context, chemiluminescence has to be put into perspective in a
wider diagnostic setting involving other adjunctive and definitive diagnostic modalities. Chemiluminescence, oral
cytology, and histopathological examination represent complementary and not competing diagnostic tools in the
evaluation of OPMDs. While histopathology is considered as the gold standard for definite diagnosis and grading of
epithelial dysplasia {Esperouz et al., 2024 #256707}, its invasiveness and limited feasibility for repeated monitoring
restrict its use as a first-line diagnostic modality.Chemiluminescence is a chairside, adjunctive technique that is
noninvasive but only of relatively high sensitivity with consistently low specificity, as confirmed by the present metaanalysis. This profile makes chemiluminescence unsuitable as a diagnostic test on its own, but may be useful for lesion
visualization and detection of clinically suspicious areas that needed to be investigated further. Oral cytology, in
particular, when carried out using liquid-based methods and supported by molecular or immunocytochemical
investigations, has reported relatively high sensitivity in the detection of epithelial dysplasia with variable but generally
higher specificity compared with chemiluminescence{Navone et al., 2007 #258959}. Thus, this minimally invasive
technique may represent an intermediate diagnostic step from clinical examination to biopsy, especially in large,
multifocal, or clinically doubtful lesions.
In the light of these considerations, it is possible to propose a stepwise diagnostic approach: initial clinical examination
in association with enhanced lesion detection and site selection guidance by chemiluminescence, oral cytology for risk
stratification in selected cases, and confirmation and grading of dysplasia through definitive histopathological
examination. An integrated diagnostic algorithm like this could achieve early detection of high-risk OPMDs while
minimizing unnecessary biopsies and optimizing clinical decision-making.
- Comment 2: The number of included cases is clearly insufficient for a meta-analysis. In our view, a substantially
larger sample size is required to ensure the robustness and reliability of the pooled estimates. We recommend increasing
the number of cases to at least 300 before drawing definitive conclusions from a meta-analytic approach
Response: We thank the Reviewer for this important observation. While the number of eligible diagnostic accuracy
studies and the overall number of included cases are limited, this reflects the current availability of primary evidence on
chemiluminescence in oral potentially malignant disorders rather than a selection bias.In response to this comment, we
have added a dedicated Limitations paragraph to the Discussion, in which we explicitly acknowledge the limited
number of studies and cases, the presence of heterogeneity, and the potential impact of these factors on the robustness of
pooled estimates. We also emphasize that the findings should be interpreted with caution and primarily support the
adjunctive role of chemiluminescence, while highlighting the need for larger, well-designed prospective studies.
We believe that this addition strengthens the transparency and methodological rigor of the manuscript without
compromising the validity of the meta-analytic approach.
Tekst change: Limitations
Limitations of the systematic review and meta-analysis conducted in this review include the following. Firstly, the
number of studies available for the calculation of the sensitivity and specificity of chemiluminescence in the diagnosis
of oral potentially malignant disorders, and also the number of participating subjects, was small. This is based on the
available evidence.Secondly, the heterogeneity found among the studies included was substantial, and this could well be
attributed to differences between the studies, including designs, types of the lesions, the chemical devices used, and the
criteria employed to determine the results positive. Though the random-effects model was employed to treat this
heterogeneity, the heterogeneity still cannot be ruled out.Third, some of the included studies used selective biopsy
approaches according to suspicion or test positivity, which might have resulted in partial verification bias.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

In this manuscript, Esperouz et al. did systematic review and meta-analysis of the diagnostic accuracy of chemiluminescence for detecting dysplasia or malignant transformation in oral potentially malignant disorders (OPMDs). They demonstrated that chemiluminescence may demonstrate good sensitivity, but has repeatedly been shown to have limited specificity in a consistent manner, particularly in populations with mixed OPMD. It may help to consider the application chemiluminescence in the diagnosis of OPMDs. I have following comments.

A systematic review and meta-analysis published in 2022 (PMID: 32847738) is about the efficacy of chemiluminescence in the diagnosis and screening of oral cancer and precancer included 16 studies. However, current study included only 13 studies. Why?

False negative result may significantly affect patients’ outcomes. Therefore, it is important to evaluate the false negative rate of detecting dysplasia or malignant transformation in oral potentially malignant disorders (OPMDs) by chemiluminescence method.

Biopsy is the gold standard for diagnose the dysplasia or malignant transformation in oral potentially malignant disorders. Some studies biopsied all lesions regardless of clinical appearance, whereas others performed biopsies selectively based on clinical suspicion or test positivity. This may cause bias and should be discussed.

Recent years, at least two systematic reviews and meta-analyses discussed the diagnostic accuracy of chemiluminescence in OPMD (PMID: 33392809; 32847738). Compared with these publications, what is new or different conclusions in current manuscript? Add this to Discussion.

Author Response

We thank the Editor and the Reviewers for their constructive comments, which helped us to improve the manuscript. We have revised the manuscript accordingly, and our point-by-point responses are provided below:

In this manuscript, Esperouz et al. did systematic review and meta-analysis of the diagnostic accuracy of
chemiluminescence for detecting dysplasia or malignant transformation in oral potentially malignant
disorders (OPMDs). They demonstrated that chemiluminescence may demonstrate good sensitivity, but has
repeatedly been shown to have limited specificity in a consistent manner, particularly in populations with
mixed OPMD. It may help to consider the application chemiluminescence in the diagnosis of OPMDs. I have
following comments.
Comment 1: A systematic review and meta-analysis published in 2022 (PMID: 32847738) is about the
efficacy of chemiluminescence in the diagnosis and screening of oral cancer and precancer included 16
studies. However, current study included only 13 studies. Why?
Response: We thank the Reviewer for this important question. The difference in the number of included
studies is primarily attributable to differences in inclusion criteria and methodological rigor. In the present
meta-analysis, we applied stricter eligibility criteria by including only in vivo clinical studies evaluating
chemiluminescence in oral potentially malignant disorders, using histopathology as the reference standard,
and providing extractable data to reconstruct 2×2 contingency tables for diagnostic accuracy analysis.As a
result, several studies included in the 2022 meta-analysis were excluded from our quantitative synthesis for
specific methodological reasons. In particular, some studies were excluded because they were conducted ex
vivo, evaluated optical modalities other than chemiluminescence (e.g., autofluorescence), included only oral
squamous cell carcinoma without OPMDs, or did not allow a direct comparison with histopathological
outcomes. Additionally, some studies did not report sufficient data to enable reconstruction of standard
diagnostic accuracy measures.These exclusions were predefined and systematically applied to enhance the
clinical interpretability and methodological robustness of the pooled estimates. The reasons for exclusion
have now been explicitly clarified in the Methods section and detailed in the list of excluded studies.
Text change: Table 1. Excluded studies Supplemental materials
Comment 2: False negative result may significantly affect patients’ outcomes. Therefore, it is important to
evaluate the false negative rate of detecting dysplasia or malignant transformation in oral potentially
malignant disorders (OPMDs) by chemiluminescence method.
Response: We thank the Reviewer for highlighting the clinical relevance of false negative results. Although the false
negative rate is inherently reflected in sensitivity estimates, we have expanded the Discussion to explicitly address the
potential clinical consequences of false negative chemiluminescence findings. In particular, we emphasize that negative
chemiluminescence results should not be interpreted as excluding epithelial dysplasia or malignant transformation and
should not replace biopsy or appropriate clinical follow-up in suspicious lesions.
Text change: From a clinical perspective, the implications of false negative results deserve particular
attention. While the sensitivity of chemiluminescence was relatively high, a false negative result cannot,
therefore, be ruled out completely. The implications, therefore, of a false negative result for
chemiluminescence might result in a delayed biopsy and subsequent diagnosis of epithelial dysplasia and
malignant change. It must, therefore, not be used to rule out a disease process when there are
chemiluminescence results that are negative.
Comment 3: Biopsy is the gold standard for diagnose the dysplasia or malignant transformation in oral
potentially malignant disorders. Some studies biopsied all lesions regardless of clinical appearance, whereas
others performed biopsies selectively based on clinical suspicion or test positivity. This may cause bias and
should be discussed.
Response : We thank the Reviewer for highlighting this important methodological concern. In response, we
have added a dedicated Limitations paragraph to the Discussion in which we explicitly address the use of
selective biopsy strategies in some of the included studies and the resulting risk of partial verification bias.
We acknowledge that this approach may have influenced the pooled diagnostic accuracy estimates and
should therefore be taken into account when interpreting the results of the present meta-analysis.
Text change: Limitations
Limitations of the systematic review and meta-analysis conducted in this review include the following. Firstly,
the number of studies available for the calculation of the sensitivity and specificity of chemiluminescence in
the diagnosis of oral potentially malignant disorders, and also the number of participating subjects, was
small. This is based on the available evidence.Secondly, the heterogeneity found among the studies
included was substantial, and this could well be attributed to differences between the studies, including
designs, types of the lesions, the chemical devices used, and the criteria employed to determine the results
positive. Though the random-effects model was employed to treat this heterogeneity, the heterogeneity still
cannot be ruled out.Third, some of the included studies used selective biopsy approaches according to
suspicion or test positivity, which might have resulted in partial verification bias.
Comment 4: Recent years, at least two systematic reviews and meta-analyses discussed the diagnostic
accuracy of chemiluminescence in OPMD (PMID: 33392809; 32847738). Compared with these publications,
what is new or different conclusions in current manuscript? Add this to Discussion.
Response: We thank the Reviewer for this important comment. In response, we have expanded the
Discussion to explicitly clarify the novelty and added clinical value of the present study compared with
previous systematic reviews and meta-analyses. Specifically, we highlighted that, unlike earlier analyses
that primarily focused on screening performance or compared multiple light-based diagnostic modalities
across heterogeneous disease entities, our work restricted inclusion to oral potentially malignant disorders
with histopathology as the mandatory reference standard. Furthermore, we performed lesion-based
analyses, particularly distinguishing leukoplakia from mixed OPMD populations, and demonstrated that
diagnostic performance is more strongly influenced by lesion characteristics, such as keratinization, than by
device type alone. In addition, we proposed a clinically oriented, stepwise diagnostic framework integrating
chemiluminescence with oral cytology and histopathological examination. These aspects and their
implications have now been explicitly addressed in the revised Discussion section.
Text change : In this context, coompared with previous systematic reviews and meta-analyses {Buenahora et
al., 2021 #60157; Kim et al., 2022 #254072} on chemiluminescence in oral potentially malignant disorders, the
present study provides a more clinically oriented perspective. While earlier analyses primarily focused on
screening performance or compared multiple light-based diagnostic modalities across heterogeneous disease
entities, this work specifically restricted inclusion to OPMDs with histopathology as the reference standard
and explored lesion-based differences in diagnostic accuracy

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Because the number of cases included in this meta-analysis is limited and the original title was considered “too definitive,” the title has been revised as follows:

　Available evidence on the diagnostic accuracy of chemiluminescence for detecting dysplasia or malignant transformation in oral potentially malignant disorders (OPMDs): a systematic review and meta-analysis.

Comments on the Quality of English Language

None

Author Response

We thank the Reviewer for the comment. The title has been revised as suggested to better reflect the limited number of included cases and has been updated in the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

Authors have improved the manuscript.

Author Response

We thank the Reviewer for the positive evaluation and helpful contribution to improving the manuscript.