Biopsy in oral surgery

1. DR KALPA PANDYA MDS, FHNS (HEAD AND NECK ONCOSURGERY)

2. - Greek word ‘bios’ and ‘opsis’ meaning life and vision respectively.
- Tissue taken from a living organism for the purpose of microscopic examination is
known as biopsy.
-Surgical procedure which involves obtaining of a living tissue specimen for
performing diagnosis.
- The current gold standard for diagnosis is the histopathologic assessment of a tissue
biopsy of the suspicious lesion
WHAT IS A BIOPSY?

3. Whenever you see an oral lesion, train yourself by using the diagnostic
sieve to list out possible clinical differential diagnoses:
Developmental (Congenital)
Inflammatory/Infection
Neoplastic
Traumatic
Autoimmune/Allergic
Oral manifestation of systemic disease
6 BASIC ETIOLOGIC CATEGORIES FOR
AN ORAL LESION

4. - Final diagnosis on the basis of histopathological features.
-Treatment planning
- Prognosis of malignant and premalignant lesions and conditions
- Morbidity and mortality of a patient as well as efficacy of the treatment.
- Document of medico-legal value
NEED OF BIOPSY???

5. INDICATIONS
For lesions that exist for more than 2 weeks
in the sit even after removal of the irritating
factor and etiology

6. INDICATIONS
Cystic lesions (usually aspiration)

7. INDICATIONS
Hard tissue lesions

8. INDICATIONS
Potentially malignant disorders
And
Suspicious changes in potentially
malignant disorders

9. INDICATIONS
Systemic Diseases

10. INDICATIONS
Infections (Mucormycosis, Osteomyelitis
etc )

11. INDICATIONS
Osteoradionecrosis

12. INDICATIONS
- Lesions causing the patient extreme
concern(journal American dental
association 2001;132:329-335)

13. RELATIVE
-1.Normal antomical & racial variations - physiologic
pigmentation,
-leukedema, Línea alba, Tori.
-2. Medically Compromised patient - (bleeding disorder / on
-anticoagulant therapy)
-3. Proximity of lesions to vital anatomic vascular, neural or
ductal
-structure
-4. Lesions - difficult access
-5. Be careful with a pigmented lesion
CONTRAINDICATIONS
ABSOLUTE
- 1.Pulsative lesion - vascular nature
- 2.Intrabony radiolucent lesion should
not be biopsied without prior
- investigational aspiration.

14. TYPES OF BIOPSY
INCISIONAL BIOPSY
EXCISIONAL BIOPSY
PUNCH BIOPSY
BRUSH BIOPSY
FNAC
TRUCUT BIOPSY

15. An incisional biopsy involves taking a small portion of the lesional tissue for
diagnostic purpose.
Incisional biopsies are commonly used:
- When a lesion is large enough that definitive removal for histologic diagnosis
would produce significant morbidity.
- When necessary to convince a patient that serious pathology exists although the
patient may not agree or may be asymptomatic.
INCISIONAL BIOPSY

17. - Medical history: Bleeding disorders, Hypertension
- Informed Consent
NEXT,

18. - Eliciting and documenting the pertinent history, including duration, any antecedent
event, symptoms and changes in appearance, as well as prior diagnostic and
therapeutic measures.
- A comprehensive examination: both visual and tactile assessment of the oral soft
tissues.
- The location, size, colour, and consistency or texture of the
- Clear photographs
- The differential diagnosis will guide management decisions, including the decision
to obtain a biopsy sample.
- Referral to a clinician with expertise in the diagnosis and management of oral
disease is always a possibility.
BEFORE YOU START,

19. 1. Local anesthetic cartridge and syringe
2. Scalpel: Blade handle with the blade or a disposable scalpel (No. 15)
3. Tissue forceps
4. Retractors
5. Needle holder and suture (4-0 or 5-0 silk sutures are commonly used intraorally)
6. Scissors
7. Gauze
8. Curved forceps, Bite block (as needed)
9. Specimen bottle with fixing solution and biopsy data sheet: 10% Neutral Buffer
Formalin
10. Tie up with a pathology lab
ARMAMENTERIUM

21. - Small lesions (<1 cm): an excisional biopsy
- Incisional biospy- selecting a site at the periphery of the lesion to ensure inclusion
of healthy tissue in the sample.
-most representative sample; an attempt to include tissue from the periphery may
inadvertently lead to underdiagnosis.
-- If there is any doubt about the malignant character of the lesion, vital staining with
toluidine blue can be use as an adjunct to select representative areas.
SELECT THE AREA TO BIOPSY

22. Toluidine blue is a basic dye that fixes to nucleic acids and stains the nuclear content
of malignant cells; in these cases samples should be taken from areas with deep blue
patches, as light blue areas are not significant. Toluidine blue is used in three steps:
• wash the area with 1% acetic acid
• apply a 1% toluidine blue water solution for 1 minute
• mouthwash with 1% acetic acid
VITAL STAINING

23. - The surgical area is disinfected with a quaternary ammonium compound.
- Iodinecontaining surface antiseptics should not be used, as they may stain the
tissues. A 0.12- 0.20 % chlorhexidine solution is preferred.
PREPARATION OF THE SURGICAL FIELD

24. An amide-type local anaesthetic with vasoconstrictor should be used and infiltrated
away from the lesion to avoid introducing artefacts in the sample.
LOCAL ANAESTHESIA:

25. An elliptical incision,is made with a size 15 scalpel blade.
The elliptical shape facilitates primary-intention closure.
The inferior incision is made first, so that hemorrhage does not obscure the surgical
field.
The anterior tip of the ellipse is gently lifted with tissue forceps, and the base is
severed.
PROCEDURE

26. - Soft tissues incisions should be elliptical in shape producing a “V” wedge that
includes both the lesion and healthy margins.
- If various lesions are present, multiple biopsies should be taken.

27. - The suture should achieve good haemostasis, facilitate healing and should be
removed after 6-8 days
HEMOSTASIS AND CLOSURE

28. - History
- Description of the lesion
- Site of the lesion with diagram
- Differential diagnosis
- Supporting reports (Scans, previous biopsy)
- Referring doctor with contact number
- Orientation suture
- Label the specimen
HISTOPATHOLOGICAL FORM

29. - While transporting the specimen to the histopathological laboratory, the specimen
should be labeled properly with the patient's name, age, date of biopsy, and site of
biopsy.
- The orientation of the specimen should be marked with the suture thread at
different labels.
- The specimen should be delivered to pathologist immediately.
- Never put specimen on paper or in tubes with cotton plugs.
SPECIMEN TRANSPORTATION:

30. In order to obtain a quality, artefact-free oral biopsy that permits the pathologist establish a
histological diagnosis, the clinician should avoid:
• pressing the sample with the tweezers, particularly if toothed, as may produce tissue tears
• Infiltrating anaesthetic solution within the lesion, as it can cause sample alterations
• applying products to the lesion that induce tissue modifications
• using an insufficient volume of fixing solution
• inclusion of undesired material in the sample: glove powder, calculus, restorative
materials, etc.
• taking insufficient amount of tissue in extension and depth.
• Do not use small strokes with the scalpel. Incisions should be continuous. Small strokes
will destroy the cell alignment of the tissue and the orientation.
• Do not cut the specimen to see what might be inside. The pathologist may want to ink the
specimen to establish the margins.
• For excisional biopsies, take enough representative tissue without damaging the tissue
integrity.
• Be aware of adjacent anatomy to avoid unnecessary tissue damage
WHAT ARE THE MOST FREQUENT ERRORS
THAT SHOULD BE AVOIDED WHEN TAKING
ORAL BIOPSIES?

31. Involves complete excision of the affected lesion for both the diagnostic and
therapeutic purposes. This type of biopsy is mostly recommended in those cases in
which the size of biopsy is small.
Advantages
• Complete removal of the lesion.8
• Most appropriate for small peripheral benign lesions.4
• For small, pedunculated, exophytic growths.3
Disadvantages
- Only a small fragment of tissue is required.11
- Difficult to perform in large lesions.
- Should be avoided in cases where a high grade malignancy is suspected.9
EXCISIONAL BIOPSY

32. - The entire lesion, along with 2-3 mm of normal appearing surroundingtissue is
excised in all directions from the periphery of the lesion.
- The depth of the lesion is also important.

33. EXCISIONAL BIOPSY
PREFERRED OVER
INCISIONAL

34. Punch biopsy is usually used as an alternative to incision biopsies for small lesion at
an accessible site. The lateral tongue and buccal mucosa are appropriate sites for
punch biopsy, as it must be feasible for device to approach the mucosal surface
perpendicularly.8
Advantages
- Experimental Pre-operative Intra-operative Post-operative
- Rapid, simple, safe and inexpensive technique for obtaining a representative
sample of most oral zones
- Good esthetic results due to better and fast wound healing.1
• The punch is able to
obtain several samples at the same time, and at different points, and generates
less patient
PUNCH BIOPSY

35. Disadvantages
- In case of larger lesions, it should be avoided as intensely vascularized or
innervated areas cannot be samples by this method.
- Not recommended in case of deep lesions and is limited to epithelial or superficial
mesenchymal target tissues.1
- Caution should be taken while biopsying areas which are near to normal
anatomical structures.
- Not indicated for vesiculo-bullous lesions.8
PUNCH BIOPSY

36. FINE NEEDLE ASPIRATION
CYTOLOGY (FNAC)

37. BRUSH BIOPSY

38. THANK
YOU