Principles and Techniques of Principles and Techniques of BiopsyBiopsy

Principles and Techniques of Principles and Techniques of BiopsyBiopsy

It is important to develop a systematic approach in evaluating a patient with a lesion in the Oral and Maxillofacial region.

These steps include :These steps include :

A detailed health historyA history of the specific lesionA clinical examinationA radiographic examinationLaboratory investigationsSurgical specimens for histopathologic

evaluation

Health HistoryHealth History

An accurate health history may disclose predisposing factors in the disease process or factors that affect the patients management.

Up to 90% of systemic deseases can be discovered through history taking.

The same can be true of oral lesions when one is familiar with the natural progression of the more common disease processes.

Medical conditions that Medical conditions that warrant special care include:warrant special care include:Congenital heart defectsCoagulopathiesHypertensionPoorly controlled diabeticsImmunocompromised patients

History of the LesionHistory of the Lesion

Questions to AskQuestions to Ask

Duration of the lesionChanges in size and rate of changeChanges in the character of the lesion.

– Lump to ulcer, etc

Associated systemic symptoms:– fever– nausea– anorexia

More Questions to AskMore Questions to Ask

PainAbnormal sensationsAnesthesiaA feeling of swellingBad taste or smell DysphagiaSwelling or tenderness of adjacent lymph

nodesCharacter of the pain if present

Historical Reasons for the Historical Reasons for the Lesions:Lesions:Trauma to the areaRecent toothacheHabits

Clinical ExaminationClinical Examination

The clinical examination should always include when possible:– Inspection– Palpation– Percussion– Auscultation

Clinical EvaluationClinical Evaluation

The anatomic location of the lesion/mass The physical character of the lesion/mass The size and shape of the lesion/mass Single vs. multiple lesions The surface of the lesion The color of the lesion The sharpness of the boundaries of the lesion The consistency of the lesion to palpation Presence of pulsation Lymph node examination

Radiographic ExaminationRadiographic Examination

The radiographic appearance may provide clues that will help determine the nature of the lesion.

A radiolucency with sharp borders will often be a cyst

A ragged radiolucency will often be a more aggressive lesion

Radiopaque dyes and instruments can help differentiate normal anatomy

Laboratory InvestigationLaboratory Investigation

Oral lesions may be manifestations of systemic disease.

If a systemic disease is suspected it should be pursued.

These include:These include:

Tumor of hyperparathyroidismPadgets diseaseMultiple myelomaDetermination of serum calcium,

phosphorus, and alkaline phosphatase and protein can be very useful in excluding certain pathological processes.

Indications for BiopsyIndications for Biopsy

Any lesion that persists for more than 2 weeks with no apparent etiologic basis

Any inflammatory lesion that does not respond to local treatment after 10 to 14 days.

Persistent hyperkeratotic changes in surface tissues.

Any persistent tumescence, either visible or palpable beneath relatively normal tissue.

Indications for BiopsyIndications for Biopsy

Inflammatory changes of unknown cause that persist for long periods

Lesion that interfere with local function Bone lesions not specifically identified by

clinical and radiographic findings Any lesion that has the characteristics of

malignancy

Characteristics of lesions that raise the Characteristics of lesions that raise the suspicion of malignancy.suspicion of malignancy.

Erythroplasia- lesion is totally red or has a speckled red appearance.

Ulceration- lesion is ulcerated or presents as an ulcer. Duration- lesion has persisted for more than two weeks. Growth rate- lesion exhibits rapid growth Bleeding- lesion bleeds on gentle manipulation Induration- lesion and surrounding tissue is firm to the

touch Fixation- lesion feels attached to adjacent structures

What is a Biopsy?What is a Biopsy?

Biopsy is the removal of tissue for the purpose of diagnostic examination.

Types of BiopsyTypes of Biopsy

Oral cytologyAspiration biopsyIncisional biopsy Excisional biopsyNeedle biopsy

Oral CytologyOral Cytology

Developed as a diagnostic screening procedure to monitor large tissue areas for dysplastic changes.

Most frequently used to screen for uterine cervix malignancy

May be helpful with monitoring postradiation changes, herpes, pemphigus.

The Disadvantage of oral cytological The Disadvantage of oral cytological procedures include:procedures include:

Not very reliable with many false positives. Expertise in oral cytology is not widely

available The lesion is repeatedly scraped with a

moistened tongue depressor or spatula type instrument. The cells obtained are smeared on a glass slide and immediately fixed with a fixative spray or solution.

Aspiration BiopsyAspiration Biopsy

Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration if its contents.

Indications:– To determine the presents of fluid within a lesion

– To a certain the type of fluid within a lesion

– When exploration of an intraosseous lesion is indicated

AspirationAspiration

An 18 gauge needle on a 5 or 10 ml syringe is inserted into the area under investigation after anesthesia is obtained.

The syringe is aspirated and the needle redirected if necessary to find the fluid cavity.

Incisional BiopsyIncisional Biopsy

An incisional biopsy is a biopsy that samples only a particular portion or representative part of a lesion.

If a lesion is large or has different characteristics in various locations more than one area may need to be sampled

Incisional BiopsyIncisional Biopsy Indications:

– Size limitations

– Hazardous location of the lesion

– Great suspicion of malignancy

Technique:– Representative areas are biopsied in a wedge fashion.

– Margins should extend into normal tissue on the deep surface.

– Necrotic tissue should be avoided.

– A narrow deep specimen is better than a broad shallow one.

Excisional BiopsyExcisional Biopsy

An excisional biposy implies the complete removal of the lesion.

Indications:– Should be employed with small lesions. Less than 1cm

– The lesion on clinical exam appears benign.

– When complete excision with a margin of normal tissue is possible without mutilation.

Excisional BiopsyExcisional Biopsy

Technique:– The entire lesion with 2 to 3mm of normal

appearing tissue surrounding the lesion is excised if benign.

Principles of SurgeryPrinciples of Surgery

AnesthesiaAnesthesia

Block anesthesia is preferred to infiltration

When blocks are not possible distant infiltration may be used

Never inject directly into the lesion

Tissue StabilizationTissue Stabilization

Digital stabilizationSpecialized retractors/forcepsRetraction suturesTowel Clips

HemostasisHemostasis

Suction devices should be avoidedGauze compresses are usually adequateGauze wrapped low volume suction may

be used if needed

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

tissue if the lesion is thought to be benign. 5mm or more may be necessary with lesions that appear

malignant, vascular, pigmented, or have diffuse borders.

Handling of the Tissue Handling of the Tissue SpecimenSpecimenDirect handling of the lesion will expose

it to crush injury resulting in alteration the cellular architecture.

Specimen CareSpecimen Care

The specimen should be immediately placed in 10% formalin solution, and be completely immersed.

Margins of the BiopsyMargins of the Biopsy

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 ClosureSurgical Closure

Primary closure of the wound is usually possible

Mucosal undermining may be necessary Elliptical incision on the hard palate or

attached gingiva may be left to heal by secondary intention.

Biopsy Data SheetBiopsy Data Sheet

A biopsy data sheet should be completed and the specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed.

Intraosseous and Hard Tissue Intraosseous and Hard Tissue BiopsyBiopsyIntraosseous lesions are most often the

result of problems associated with the dentition.

Indications for Intraosseous Indications for Intraosseous BiopsyBiopsyAny intraosseous lesion that fails to

respond to routine treatment of the dentition.

Any intraosseous lesion that appears unrelated to the dentition.

Palpation of the area of the lesion with comparison to the opposite side.

Any radiolucent lesion should have an aspiration biopsy performed prior to surgical exploration.– Information from the aspiration will provide valuable

information about the lesion. • Solid

• Fluid Filled

• Vascular

• Without Contents

Clinical ExamClinical Exam

Principles of SurgeryPrinciples of Surgery

Mucperiosteal flaps should be designed to allow adequate access for incisional/excisional biopsy.

Incisions should be over sound bone Cortical perforation must be considered when

designing flaps Flaps should be full thickness Major neurovascular structures should be avoided

Principles of SurgeryPrinciples of Surgery

Osseous windows should be submitted with the specimen

Osseous preformations can be enlarged to gain access

Avoid roots and neurovascular structures The tissue consistency and nature of the lesion will

determine the ease of removal

Principles of SurgeryPrinciples of Surgery

Incisional biopsies only require removal of a section of tissue

Soft tissue overlying the lesion should be reapproximated following thorough irrigation of the operative site.

The specimen should be handled as previously described

Biopsy Results: What If ?Biopsy Results: What If ?

They don’t corroborate your clinical impression– Repeat the biopsy!!!

– Determine if the tissue was looked at by an Oral Pathologist

– The results show malignancy

When To Refer For BiopsyWhen To Refer For Biopsy

When the health of the patient requires special management that the dentist feel unprepared to handle

The size and surgical difficulty is beyond the level of skill that the dentist feels he/she possesses

If the dentist is concerned about the possibility of malignancy