Definition

y Biopsy is a surgical procedure to obtain

tissue from a living organism for its microscopical examination, usually to perform a diagnosis.

Indications for Biopsy

y Inflammatory changes of unknown cause that

persist for long periods y Lesion that interfere with local function y Bone lesions not specifically identified by clinical and radiographic findings y Any lesion that has the characteristics of malignancy

Characteristics of lesions that raise the suspicion of malignancy.

y Erythroplasia- lesion is totally red or has a speckled red appearance. y Ulceration- lesion is ulcerated or presents as an ulcer. y Duration- lesion has persisted for more than two weeks. y Growth rate- lesion exhibits rapid growth y Bleeding- lesion bleeds on gentle manipulation y Induration- lesion and surrounding tissue is firm to the touch y Fixation- lesion feels attached to adjacent structures

Types of Biopsy
y The four major types of biopsy routinely used in and

around the oral cavity are : y cytology, y aspiration biopsy, y incisional biopsy, y and excisional biopsy.

Oral Cytology
y Oral cytology is typically used as an adjunct to, not a

substitute for, incisional or excisional biopsy procedures y Cytology allows examination of individual cells, but cannot provide the histologic features crucial for an accurate and definitive diagnosis y Developed as a diagnostic screening procedure to monitor large tissue areas for dysplastic changes. y Lesions that lend themselves to cytologic examination may include; post-radiation changes, herpes, fungal infections, and pemphigus.

Procedures of cytological biopsy

y In a cytologic examination, the lesion is scraped

repeatedly and firmly with a moistened tongue depressor or cytology brush. y The cells are then transferred to and smeared evenly on a glass slide. y The slide is immediately immersed in a fixing solution or sprayed with a fixative, such as hairspray. y The cells can be stained with any of a myriad of laboratory preparations and examined under the microscope.

The Advantages andDisadvantage of oral cytological procedures include:

Advantages y Cytology may be helpful when large areas of mucosal change are noted, or in areas with difficult surgical access Disadvantages y Not very reliable with many false positives. y Expertise in oral cytology is not widely available

Aspiration Biopsy
y Aspiration biopsy is the use of a needle and syringe to

remove a sample of cells or contents of a lesion. y The inability to withdraw fluid or air indicates that the lesion is probably solid

Aspiration Biopsy
Indications:
y To determine the presents of fluid within a lesion y To a certain the type of fluid within a lesion y When exploration of an intraosseous lesion is indicated

Aspiration
Procedures:
y An 18-gauge needle is connected to a 5 or 10 ml syringe and is inserted into the center of the mass via a small hole in the lesion. y The tip of the needle may need to be positioned in multiple directions to locate a potential fluid center. y The material withdrawn during aspiration biopsy can be submitted for pathologic examination and/or culturing.

y The inability to withdraw fluid or air indicates that the

lesion is probably solid. y A radiolucent lesion in the jaw that yields strawcolored fluid on aspiration is most likely a cystic lesion. y If purulent exudate (pus) is withdrawn, then an inflammatory or infectious process should be considered..

y The aspiration of blood might indicate a vascular

malformation within the bone. y Any intrabony radiolucent lesion should be aspirated before surgical intervention to rule out a vascular lesion. y If the lesion is determined to be vascular in nature, the flow rate (high versus low) should be determined because uncontrollable hemorrhage can occur if incised

Incisional Biopsy
y The intent of an incisional biopsy is to sample only a

representative portion of the lesion. y If the lesion is large or has many differing characteristics, more than one area may require sampling.

Incisional Biopsy

Indications of incisional biopsy

y whenever the lesion is difficult to excise because of its

extensive size y in cases where appropriate excisional surgical management requires hospitalization or complicated wound management.

Technique of Incisional Biopsy

y Representative areas are biopsied in a wedge fashion.
y Margins should extend into normal tissue on the deep

surface. y Necrotic tissue should be avoided.

The sample should be taken from the edge of the lesion to include surrounding normal tissue y It should be deep enough to include underlying changes of the surface lesion.
y

Incisional biopsy

Punch biopsy

Punch biopsy
y . Another tool that can be used for incisional or

excisional purposes. y biopsy is especially well suited for diagnosis of oral manifestations of mucocutaneous and vesiculoulcerative diseases, such as lichen planus, pemphigus, etc

Punch biopsy

Brush biopsy
y Firm pressure with a circular

brush is applied, rotated five to ten times, causing light abrasion.

 The cellular material picked

up by the brush is transferred to a glass slide, preserved, and dried.

Technique of punch biopsy

y biopsy punches should range in size from 2-10 mm in

diameter y the smaller diameters should be avoided due to the risk of over-manipulating and crushing the tissue . y The technique is easily performed with a low incidence of postsurgical morbidity. y Suturing in regards to a punch biopsy procedure is usually not required as the surgical wounds heal by secondary intention.

Disadvantages
y One disadvantage of using the biopsy punch is that it

is difficult to obtain adequate, representative tissue deeper than the superficial lamina propria (1).

Excisional Biopsy
Indications:
y Should be employed with small lesions. Less than 1cm y The lesion on clinical exam appears benign. y When complete excision with a margin of normal tissue is

possible without mutilation.

Technique
y An excisional biposy implies the complete removal of the lesion.

y A perimeter of normal tissue (2-3 mm) surrounding the lesion is included with the specimen. y Excisional biopsy should be performed on smaller lesions (less than 1 cm in diameter) that appear clinically benign. y Pigmented and vascular lesions should be removed, if possible, in their entirety. This avoids seeding of the melanin producing tumor cells into the wound site or in the case of a hemangioma, allows the clinician to address the feeder vessels.

Exisional biopsy

Anesthesia
y Block anesthesia is preferred to infiltration y When blocks are not possible distant infiltration may

be used y Never inject directly into the lesion

Tissue Stabilization
y Digital stabilization y Specialized retractors/forceps y Retraction sutures y Towel Clips

Hemostasis
y Suction devices should be avoided y Gauze compresses are usually adequate y Gauze wrapped low volume suction may be used if

needed

Incisions
y Incisions should be made with a scalpel. y They should be converging y Should extend beyond the suspected depth of the lesion y They should parallel important structures y Margins should include 2 to 3mm of normal appearing

tissue if the lesion is thought to be benign. y 5mm or more may be necessary with lesions that appear malignant, vascular, pigmented, or have diffuse borders.

Handling of the Tissue Specimen

y special care should be undertaken to hold the

specimen gently at the periphery of the sample. y Injection of large amounts of anesthetic solution in the biopsy area, while providing hemostasis, can produce hemorrhage, which masks the normal cellular architecture. y Infiltration of local anesthetic around the lesion is acceptable if the field is wide enough in relation to the lesion;

Handling of the Tissue Specimen

y injection directly into the lesion should be avoided. y Use of electrocautery to excise the specimen remains a common complicating factor in determining an accurate microscopic diagnosis. y Heat produced by these units alters both the epithelium and the underlying connective. y Small tissue biopsies to rule out malignancy are usually nondiagnostic if excised by electrocautery, as the presence of epithelial atypia is typically obscured y If electrocautery is to be used, the incision margin should be far enough away from the interface of the lesion to prevent thermal changes at that interface (2). y

Specimen Care
y The specimen should be immediately placed in 10%

formalin solution, and be completely immersed.

Margins of the Biopsy

y Margins of the tissue should be identified to orient the

pathologist. A silk suture is often adequate. Illustrations are also very helpful and should be included.

Surgical Closure
y Primary closure of the wound is usually possible y Mucosal undermining may be necessary y Elliptical incision on the hard palate or attached

gingiva may be left to heal by secondary intention.

Biopsy Data Sheet

y A biopsy data sheet should be completed and the

specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed.

The biopsy report

It should include y the name of the clinician, y date the specimen was obtained y pertinent characteristics of the specimen.

y The location/site, size, color, number, borders or

margins, consistency, and relative radiodensity of the lesion are all important findings that should be included in the description of the specimen. y If the lesion is evident on radiographs, it is very important to submit good quality radiographs with the specimen to aid in pathologic correlation and diagnosis.

Intraosseous and Hard Tissue Biopsy

y Intraosseous lesions are most often the result of

problems associated with the dentition.

Indications for Intraosseous Biopsy

y Any intraosseous lesion that fails to respond to routine

treatment of the dentition. y Any intraosseous lesion that appears unrelated to the dentition.

Principles of Surgery
y Mucperiosteal flaps should be designed to allow

adequate access for incisional/excisional biopsy. y Incisions should be over sound bone y Cortical perforation must be considered when designing flaps y Flaps should be full thickness y Major neurovascular structures should be avoided

Principles of Surgery
y Osseous windows should be submitted with the

specimen y Osseous preformations can be enlarged to gain access y Avoid roots and neurovascular structures y The tissue consistency and nature of the lesion will determine the ease of removal

Principles of Surgery
y Incisional biopsies only require removal of a

section of tissue y Soft tissue overlying the lesion should be reapproximated following thorough irrigation of the operative site. y The specimen should be handled as previously described

When To Refer For Biopsy

y When the health of the patient requires special management that the dentist feel unprepared to handle y The size and surgical difficulty is beyond the level of skill that the dentist feels he/she possesses y If the dentist is concerned about the possibility of malignancy

References
y 1. Lynch DP, Morris LF. The oral mucosal punch

biopsy: indica-tions and technique. J Am Dent Assoc 1990 Jul;121(1):145-9. y 2. Margarone JE, Natiella JR, Vaughan CD. Artifacts in oral biopsy specimens. J Oral Maxillofac Surg 1985 Mar;43(3):163-72. y 3. Sheehan DC, Hrapchak BB. Theory and practice of histo-technology. Saint Louis: C. V. Mosby Co.; 1973. y Dent Assoc 1996 Mar;127(3):363-8.

y 4. Abbey LM, Sweeney WT. Fixation artifacts in oral

biopsy specimens. Va Dent J 1972 Dec;49(6):31-4. y 5. Zegarelli DJ. Common problems in biopsy procedure. J Oral Surg 1978 Aug;36(8):644-7. y 6.Sol Silverman, L Roy Eversole , Edmond L. Truelove, Essentials of Oral Medicine .Hamilton, Ontario 2002 BC Decker Inc