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Oral Biopsy
Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University
Definition:
Biopsy is a Greek derived word, Bios = life and
Opsis = vision
Biopsy is the removal of the tissue from the living
organism for the purpose of microscopic examination
and diagnosis (1)
There are oral lesions whose diagnosis can be
made relying on data collected during history
taking and /or physical examinations, but there
are others where histopathologic examinations
are needed to confirm the presumed clinical
diagnosis. Looking for a definitive diagnosis is
the aim of biopsy
The aim of biopsy is to :
 Define a lesion on the basis of its histopathological
aspect
 To establish a prognosis in malignant and
premalignant lesions
 Facilitate the prescription of specific treatment
 Contribute to the assessment of the efficacy of the
treatment
 To determine whether an abnormality has been
completely removed.
• Act as a document with medical-legal value
(2)
Biopsy is indicated for diagnostic confirmation
of suspected malignant lesions, precancerous
lesions such as leukoplakias or erythoplakias
and chronic ulcerations of unknown cause, and
is recommended for apparently inflammatory
lesions that do not improve within two weeks
of removal of local irritants
Oral Biopsy
Oral Biopsy
Oral Biopsy
Other lesions that should also be biopsied include:
 Lesions that interfere with oral function, such as
fibrous hyperplasias and osseous lumps
 Lesions of unclear etiology, particularly when
associated with pain, paraesthesia or anaesthesia
 Radiolucent or radio-opaque osseous lesions
Biopsy is also indicated for the histological
confirmation of certain systemic disorders. Such as
biopsy of minor salivary glands is for the diagnosis of
Sjögren's syndrome
.
 There is no need to biopsy normal structures
 There is no need to biopsy irritative or traumatic
lesions that respond to the removal of a presumed
local irritant
 There is no need to biopsy inflammatory or
infections lesions that respond to specific local
treatments, as pericoronitis, gingivitis or periodontal
abscesses
1. When the general health condition of the patient is
very poor
2. When acute, virulent, pyogenic infection is present
3. Pulsating lesions (those of vascular nature)
4. Pigmented lesions (melanoma) should not biopsied
as it may transform into malignant by cutting through
it or may spread to distant organs
5. Biopsy is not advised in the case of multiple
neurofibromas, due to the risk of neurosarcomatous
transformation, or in tumors of the major salivary
glands. Such biopsies must be performed by
specialized surgeons, in order to avoid damaging
nearby anatomical structures and causing the spread
of tumor cells, as this would adversely affect the
prognosis (3)
Feature of the lesion
• Direct biopsy: when the lesion is located on
the oral mucosa and can be easily accessed
with a scalpel from the mucosal surface
• Indirect biopsy: when the lesion is covered by
an apparently normal oral mucosa
(4)
Area of surgical removal:
• Incisional biopsy: consists of the removal of a
representive sample of the lesion and normal adjacent
tissue in order to make a definitive diagnosis before
treatment
• Excisional biopsy: is aimed at the complete surgical
removal of the lesion for diagnostic and therapeutic
purposes
Timing of the biopsy:
• Pre-operative
• Intra-operative
• Post-operative, when aimed at checking the
efficiency of a treatment
Before the procedure is undertaken, the characteristics
of the lesion (size, shape, colour, texture, consistency,
time of evolution, associated signs and symptoms,
regional nodes) should be described in the patient’s
clinical records together with a presumed diagnosis
and possible differential diagnosis. The patient should
receive information on the reasons why it is
performed, avoiding terms that may cause anxiety.
Informed consent is required
Technique simple, only a portion of the
lesion is removed
Selects a representive portion of the lesion,
especially select areas most likely to
demonstrate most advanced disease
 Biopsy of a wedge of representative tissue
 Several regions may be sampled
 Avoid necrotic tissue
 Areas of tissue transition can be useful,
such as the margin of the lesion
 Wedge should be deep enough to sample
the full depth of the lesion and its transition
to normal tissue
Incisional Biopsy;
Importance of obtaining a deep tissue specimen
 Removes the entire lesion at the time of
tissue sampling
 A margin of normal tissue is generally
included
 Offers the advantage of definitive
treatment at the time of diagnosis
Indications:
•Smaller lesions, < 1cm
•Pigmented and small vascular
lesions
•Benign lesions
Principle: lesion and 2-3mm
margin of normal tissue is
excised
Excisional Biopsy
Elliptical incision is carried-out allowing for a narrow rim
of normal peripheral tissue
Beveling your incisions to a narrow “V”
base facilitates wound closure
This type of biopsy is used mainly for intra-osseous
lesions
A drill in a dental engine is used to remove a core
from the centre of the tumour
Aspiration of cells or fluid for subsequent analysis
Technique consists of repeatedly passing a needle,
under negative pressure, through a lesion to collect
cells. The technique is usually indicated for lesions of
major salivary glands and neck masses
Fluid aspirated from a lesion can also be sampled
Generally requires analysis by a cytopathologist
Oral Biopsy
This is quick method of diagnosis that can be
used during surgery to make sure that the
margin of the lesion is clear
Frozen sections for tumour diagnosis usually
provide a rapid and highly reliable answer and
the only problem may be that of conveying the
specimen from theatre to laboratory rapidly and
without deterioration
Resection of a malignant lesion requires
removal of a significant margin of normal
tissue. Inadequate margins means recurrence.
The margins of resection are determined by
visual inspection and palpation of the lesion.
This is very difficult to do if the lesion is gone!
Local anesthesia
Careful not to distort your margins
Haemostasis
Sponge > suction
Incision
Scalpel/punch
2-3mm of normal tissue
Tissue Handling
Gentle, do not crush your specimen
Identification of margins
Sutures for orientation
Specimen care
Gentle handling with forceps
Closure
Undermining as needed
Pathology Sheet
Be descriptive
There are different procedures for undertaking
oral biopsies. It has been widely accepted that
scalpel is the best surgical instrument for
obtaining oral biopsies. The use of CO2 laser is
compromised by thermal cytological artifacts.
The same is also applied to electrosurgical
units(5)
The biopsy should be large enough to include
normal and suspicious tissue and for the
pathologist to give a diagnosis without further
specimens. Small samples are difficult to
orientate and handle and certain processes as
sample fixation may end in reduction of the
size of the specimen
Samples must be oriented with a suture or a piece of
paper, and introduced in a container with a fixing
solution (10% formalin). The number and location of
the biopsies will be decided on the basis of the clinical
appearance of the lesion. If a lesion shows several
areas where biopsy would be indicated, more than one
sample should be taken. In these cases with
precancerous or suspicious lesions, toluidine blue
staining could be useful to choose the areas most
relevant to biopsy
Toluidine blue displays affinity for areas of dysplasia,
malignancy and high cell turn over
(6)
 Taking insufficient amount of tissue in extension and
depth
 Pressing the sample with tweezers, producing tissue
tears
 Infiltrating anaesthetic solution within the lesion
 Using an insufficient volume of fixing solution
 Inclusion of undesired material in the sample; glove
powder, calculus, restorative materials, etc.
 Discovering a lesion is the first step to
making a diagnosis
 If you find yourself 10 years into practice and
you have not diagnosed any dysplasia, you are
missing lesions guaranteed !!
 Not all tumors are cancers, and not all
cancers are tumors
 Diagnosing cancer is as important as treating
caries !!
Oral Biopsy
1. Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology, 3rd
ed.,W W,B, Saunders Com. Pp 545,1974.
2. Karkera BV, et al. Biopsy: Clinical implications. J Dent Oral Hygiene.
3:106,2011.
3. Mota-Ramírez A , Silvestre F J , Simó J M. Oral biopsy in dental
practice. Med Oral Patol Oral Cir Bucal.12:E504, 2007.
4. Oliver RJ, Sloan P, Pemberton MN. Oral biopsies: methods and
applications. Brit Dental J. 16:329,2004.
5. Rosebush MS, et al. The Oral biopsy: Indications, techniques and
special considerations. J Tenn Dent Assoc. 90,2010.
6. Siddiqui IA, et al. Role of toluidine blue in early detection of oral
cancer. Pak J Med Sci Q. 22:184,2006.

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Oral Biopsy

  • 2. Dr. Ahmed M. Adawy Professor Emeritus, Dep. Oral & Maxillofacial Surg. Former Dean, Faculty of Dental Medicine Al-Azhar University
  • 3. Definition: Biopsy is a Greek derived word, Bios = life and Opsis = vision Biopsy is the removal of the tissue from the living organism for the purpose of microscopic examination and diagnosis (1)
  • 4. There are oral lesions whose diagnosis can be made relying on data collected during history taking and /or physical examinations, but there are others where histopathologic examinations are needed to confirm the presumed clinical diagnosis. Looking for a definitive diagnosis is the aim of biopsy
  • 5. The aim of biopsy is to :  Define a lesion on the basis of its histopathological aspect  To establish a prognosis in malignant and premalignant lesions  Facilitate the prescription of specific treatment  Contribute to the assessment of the efficacy of the treatment  To determine whether an abnormality has been completely removed. • Act as a document with medical-legal value (2)
  • 6. Biopsy is indicated for diagnostic confirmation of suspected malignant lesions, precancerous lesions such as leukoplakias or erythoplakias and chronic ulcerations of unknown cause, and is recommended for apparently inflammatory lesions that do not improve within two weeks of removal of local irritants
  • 10. Other lesions that should also be biopsied include:  Lesions that interfere with oral function, such as fibrous hyperplasias and osseous lumps  Lesions of unclear etiology, particularly when associated with pain, paraesthesia or anaesthesia  Radiolucent or radio-opaque osseous lesions Biopsy is also indicated for the histological confirmation of certain systemic disorders. Such as biopsy of minor salivary glands is for the diagnosis of Sjögren's syndrome .
  • 11.  There is no need to biopsy normal structures  There is no need to biopsy irritative or traumatic lesions that respond to the removal of a presumed local irritant  There is no need to biopsy inflammatory or infections lesions that respond to specific local treatments, as pericoronitis, gingivitis or periodontal abscesses
  • 12. 1. When the general health condition of the patient is very poor 2. When acute, virulent, pyogenic infection is present 3. Pulsating lesions (those of vascular nature) 4. Pigmented lesions (melanoma) should not biopsied as it may transform into malignant by cutting through it or may spread to distant organs
  • 13. 5. Biopsy is not advised in the case of multiple neurofibromas, due to the risk of neurosarcomatous transformation, or in tumors of the major salivary glands. Such biopsies must be performed by specialized surgeons, in order to avoid damaging nearby anatomical structures and causing the spread of tumor cells, as this would adversely affect the prognosis (3)
  • 14. Feature of the lesion • Direct biopsy: when the lesion is located on the oral mucosa and can be easily accessed with a scalpel from the mucosal surface • Indirect biopsy: when the lesion is covered by an apparently normal oral mucosa (4)
  • 15. Area of surgical removal: • Incisional biopsy: consists of the removal of a representive sample of the lesion and normal adjacent tissue in order to make a definitive diagnosis before treatment • Excisional biopsy: is aimed at the complete surgical removal of the lesion for diagnostic and therapeutic purposes
  • 16. Timing of the biopsy: • Pre-operative • Intra-operative • Post-operative, when aimed at checking the efficiency of a treatment
  • 17. Before the procedure is undertaken, the characteristics of the lesion (size, shape, colour, texture, consistency, time of evolution, associated signs and symptoms, regional nodes) should be described in the patient’s clinical records together with a presumed diagnosis and possible differential diagnosis. The patient should receive information on the reasons why it is performed, avoiding terms that may cause anxiety. Informed consent is required
  • 18. Technique simple, only a portion of the lesion is removed Selects a representive portion of the lesion, especially select areas most likely to demonstrate most advanced disease
  • 19.  Biopsy of a wedge of representative tissue  Several regions may be sampled  Avoid necrotic tissue  Areas of tissue transition can be useful, such as the margin of the lesion  Wedge should be deep enough to sample the full depth of the lesion and its transition to normal tissue
  • 20. Incisional Biopsy; Importance of obtaining a deep tissue specimen
  • 21.  Removes the entire lesion at the time of tissue sampling  A margin of normal tissue is generally included  Offers the advantage of definitive treatment at the time of diagnosis
  • 22. Indications: •Smaller lesions, < 1cm •Pigmented and small vascular lesions •Benign lesions Principle: lesion and 2-3mm margin of normal tissue is excised
  • 23. Excisional Biopsy Elliptical incision is carried-out allowing for a narrow rim of normal peripheral tissue
  • 24. Beveling your incisions to a narrow “V” base facilitates wound closure
  • 25. This type of biopsy is used mainly for intra-osseous lesions A drill in a dental engine is used to remove a core from the centre of the tumour
  • 26. Aspiration of cells or fluid for subsequent analysis Technique consists of repeatedly passing a needle, under negative pressure, through a lesion to collect cells. The technique is usually indicated for lesions of major salivary glands and neck masses Fluid aspirated from a lesion can also be sampled Generally requires analysis by a cytopathologist
  • 28. This is quick method of diagnosis that can be used during surgery to make sure that the margin of the lesion is clear Frozen sections for tumour diagnosis usually provide a rapid and highly reliable answer and the only problem may be that of conveying the specimen from theatre to laboratory rapidly and without deterioration
  • 29. Resection of a malignant lesion requires removal of a significant margin of normal tissue. Inadequate margins means recurrence. The margins of resection are determined by visual inspection and palpation of the lesion. This is very difficult to do if the lesion is gone!
  • 30. Local anesthesia Careful not to distort your margins Haemostasis Sponge > suction Incision Scalpel/punch 2-3mm of normal tissue Tissue Handling Gentle, do not crush your specimen
  • 31. Identification of margins Sutures for orientation Specimen care Gentle handling with forceps Closure Undermining as needed Pathology Sheet Be descriptive
  • 32. There are different procedures for undertaking oral biopsies. It has been widely accepted that scalpel is the best surgical instrument for obtaining oral biopsies. The use of CO2 laser is compromised by thermal cytological artifacts. The same is also applied to electrosurgical units(5)
  • 33. The biopsy should be large enough to include normal and suspicious tissue and for the pathologist to give a diagnosis without further specimens. Small samples are difficult to orientate and handle and certain processes as sample fixation may end in reduction of the size of the specimen
  • 34. Samples must be oriented with a suture or a piece of paper, and introduced in a container with a fixing solution (10% formalin). The number and location of the biopsies will be decided on the basis of the clinical appearance of the lesion. If a lesion shows several areas where biopsy would be indicated, more than one sample should be taken. In these cases with precancerous or suspicious lesions, toluidine blue staining could be useful to choose the areas most relevant to biopsy
  • 35. Toluidine blue displays affinity for areas of dysplasia, malignancy and high cell turn over (6)
  • 36.  Taking insufficient amount of tissue in extension and depth  Pressing the sample with tweezers, producing tissue tears  Infiltrating anaesthetic solution within the lesion  Using an insufficient volume of fixing solution  Inclusion of undesired material in the sample; glove powder, calculus, restorative materials, etc.
  • 37.  Discovering a lesion is the first step to making a diagnosis  If you find yourself 10 years into practice and you have not diagnosed any dysplasia, you are missing lesions guaranteed !!  Not all tumors are cancers, and not all cancers are tumors  Diagnosing cancer is as important as treating caries !!
  • 39. 1. Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology, 3rd ed.,W W,B, Saunders Com. Pp 545,1974. 2. Karkera BV, et al. Biopsy: Clinical implications. J Dent Oral Hygiene. 3:106,2011. 3. Mota-Ramírez A , Silvestre F J , Simó J M. Oral biopsy in dental practice. Med Oral Patol Oral Cir Bucal.12:E504, 2007. 4. Oliver RJ, Sloan P, Pemberton MN. Oral biopsies: methods and applications. Brit Dental J. 16:329,2004. 5. Rosebush MS, et al. The Oral biopsy: Indications, techniques and special considerations. J Tenn Dent Assoc. 90,2010. 6. Siddiqui IA, et al. Role of toluidine blue in early detection of oral cancer. Pak J Med Sci Q. 22:184,2006.