Principles and Techniques of Biopsy
Principles and Techniques of Biopsy <ul><li>It is important to develop a systematic approach in evaluating a patient with ...
These steps include : <ul><li>A detailed health history </li></ul><ul><li>A history of the specific lesion </li></ul><ul><...
Health History <ul><li>An accurate health history may disclose predisposing factors in the disease process or factors that...
Medical conditions that warrant special care include: <ul><li>Congenital heart defects </li></ul><ul><li>Coagulopathies </...
History of the Lesion
Questions to Ask <ul><li>Duration of the lesion </li></ul><ul><li>Changes in size and rate of change </li></ul><ul><li>Cha...
More Questions to Ask <ul><li>Pain </li></ul><ul><li>Abnormal sensations </li></ul><ul><li>Anesthesia </li></ul><ul><li>A ...
Historical Reasons for the Lesions: <ul><li>Trauma to the area </li></ul><ul><li>Recent toothache </li></ul><ul><li>Habits...
Clinical Examination <ul><li>The clinical examination should always include when possible: </li></ul><ul><ul><li>Inspectio...
Clinical Evaluation <ul><li>The anatomic location of the lesion/mass </li></ul><ul><li>The physical character of the lesio...
Radiographic Examination <ul><li>The radiographic appearance may provide clues that will help determine the nature of the ...
Laboratory Investigation <ul><li>Oral lesions may be manifestations of systemic disease.  </li></ul><ul><li>If a systemic ...
These include: <ul><li>Tumor of hyperparathyroidism </li></ul><ul><li>Padgets disease </li></ul><ul><li>Multiple myeloma <...
Indications for Biopsy <ul><li>Any lesion that persists for more than 2 weeks with no apparent etiologic basis </li></ul><...
Indications for Biopsy <ul><li>Inflammatory changes of unknown cause that persist for long periods </li></ul><ul><li>Lesio...
Characteristics of lesions that raise the suspicion of malignancy. <ul><li>Erythroplasia-  lesion is totally red or has a ...
What is a Biopsy? <ul><li>Biopsy is the removal of tissue for the purpose of diagnostic examination.  </li></ul>
Types of Biopsy <ul><li>Oral cytology </li></ul><ul><li>Aspiration biopsy </li></ul><ul><li>Incisional biopsy  </li></ul><...
Oral Cytology <ul><li>Developed as a diagnostic screening procedure to monitor large tissue areas for dysplastic changes. ...
The Disadvantage of oral cytological procedures include: <ul><li>Not very reliable with many false positives. </li></ul><u...
Aspiration Biopsy <ul><li>Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration if its...
Aspiration <ul><li>An 18 gauge needle on a 5 or 10 ml syringe is inserted into the area under investigation after anesthes...
Incisional Biopsy <ul><li>An incisional biopsy is a biopsy that samples only a particular portion or representative part o...
Incisional Biopsy <ul><li>Indications: </li></ul><ul><ul><li>Size limitations  </li></ul></ul><ul><ul><li>Hazardous locati...
Excisional Biopsy <ul><li>An excisional biposy implies the complete removal of the lesion. </li></ul><ul><li>Indications: ...
Excisional Biopsy <ul><li>Technique: </li></ul><ul><ul><li>The entire lesion with 2 to 3mm of normal appearing tissue surr...
Principles of Surgery
Anesthesia <ul><li>Block anesthesia is preferred to infiltration </li></ul><ul><li>When blocks are not possible distant in...
Tissue Stabilization <ul><li>Digital stabilization </li></ul><ul><li>Specialized retractors/forceps </li></ul><ul><li>Retr...
Hemostasis <ul><li>Suction devices should be avoided </li></ul><ul><li>Gauze compresses are usually adequate </li></ul><ul...
Incisions <ul><li>Incisions should be made with a scalpel. </li></ul><ul><li>They should be converging </li></ul><ul><li>S...
Handling of the Tissue Specimen <ul><li>Direct handling of the lesion will expose it to crush injury resulting in alterati...
Specimen Care <ul><li>The specimen should be immediately placed in 10% formalin solution, and be completely immersed. </li...
Margins of the Biopsy <ul><li>Margins of the tissue should be identified to orient the pathologist.  A silk suture is ofte...
Surgical Closure <ul><li>Primary closure of the wound is usually possible  </li></ul><ul><li>Mucosal undermining may be ne...
Biopsy Data Sheet <ul><li>A biopsy data sheet should be completed and the specimen immediately labeled.  All pertinent his...
Intraosseous and Hard Tissue Biopsy <ul><li>Intraosseous lesions are most often the result of problems associated with the...
Indications for Intraosseous Biopsy <ul><li>Any intraosseous lesion that fails to respond to routine treatment of the dent...
<ul><li>Palpation of the area of the lesion with comparison to the opposite side. </li></ul><ul><li>Any radiolucent lesion...
Principles of Surgery <ul><li>Mucperiosteal flaps should be designed to allow adequate access for incisional/excisional bi...
Principles of Surgery <ul><li>Osseous windows should be submitted with the specimen </li></ul><ul><li>Osseous preformation...
Principles of Surgery <ul><li>Incisional biopsies only require removal of a section of tissue </li></ul><ul><li>Soft tissu...
Biopsy Results: What If ? <ul><li>They don’t corroborate your clinical impression </li></ul><ul><ul><li>Repeat the biopsy!...
When To Refer For Biopsy <ul><li>When the health of the patient requires special management that the dentist feel unprepar...
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Biopsy in oral surgery

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Biopsy in oral surgery

  1. 1. Principles and Techniques of Biopsy
  2. 2. Principles and Techniques of Biopsy <ul><li>It is important to develop a systematic approach in evaluating a patient with a lesion in the Oral and Maxillofacial region. </li></ul>
  3. 3. These steps include : <ul><li>A detailed health history </li></ul><ul><li>A history of the specific lesion </li></ul><ul><li>A clinical examination </li></ul><ul><li>A radiographic examination </li></ul><ul><li>Laboratory investigations </li></ul><ul><li>Surgical specimens for histopathologic evaluation </li></ul>
  4. 4. Health History <ul><li>An accurate health history may disclose predisposing factors in the disease process or factors that affect the patients management. </li></ul><ul><li>Up to 90% of systemic deseases can be discovered through history taking. </li></ul><ul><li>The same can be true of oral lesions when one is familiar with the natural progression of the more common disease processes. </li></ul>
  5. 5. Medical conditions that warrant special care include: <ul><li>Congenital heart defects </li></ul><ul><li>Coagulopathies </li></ul><ul><li>Hypertension </li></ul><ul><li>Poorly controlled diabetics </li></ul><ul><li>Immunocompromised patients </li></ul>
  6. 6. History of the Lesion
  7. 7. Questions to Ask <ul><li>Duration of the lesion </li></ul><ul><li>Changes in size and rate of change </li></ul><ul><li>Changes in the character of the lesion. </li></ul><ul><ul><li>Lump to ulcer, etc </li></ul></ul><ul><li>Associated systemic symptoms: </li></ul><ul><ul><li>fever </li></ul></ul><ul><ul><li>nausea </li></ul></ul><ul><ul><li>anorexia </li></ul></ul>
  8. 8. More Questions to Ask <ul><li>Pain </li></ul><ul><li>Abnormal sensations </li></ul><ul><li>Anesthesia </li></ul><ul><li>A feeling of swelling </li></ul><ul><li>Bad taste or smell </li></ul><ul><li>Dysphagia </li></ul><ul><li>Swelling or tenderness of adjacent lymph nodes </li></ul><ul><li>Character of the pain if present </li></ul>
  9. 9. Historical Reasons for the Lesions: <ul><li>Trauma to the area </li></ul><ul><li>Recent toothache </li></ul><ul><li>Habits </li></ul>
  10. 10. Clinical Examination <ul><li>The clinical examination should always include when possible: </li></ul><ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Palpation </li></ul></ul><ul><ul><li>Percussion </li></ul></ul><ul><ul><li>Auscultation </li></ul></ul>
  11. 11. Clinical Evaluation <ul><li>The anatomic location of the lesion/mass </li></ul><ul><li>The physical character of the lesion/mass </li></ul><ul><li>The size and shape of the lesion/mass </li></ul><ul><li>Single vs. multiple lesions </li></ul><ul><li>The surface of the lesion </li></ul><ul><li>The color of the lesion </li></ul><ul><li>The sharpness of the boundaries of the lesion </li></ul><ul><li>The consistency of the lesion to palpation </li></ul><ul><li>Presence of pulsation </li></ul><ul><li>Lymph node examination </li></ul>
  12. 12. Radiographic Examination <ul><li>The radiographic appearance may provide clues that will help determine the nature of the lesion. </li></ul><ul><li>A radiolucency with sharp borders will often be a cyst </li></ul><ul><li>A ragged radiolucency will often be a more aggressive lesion </li></ul><ul><li>Radiopaque dyes and instruments can help differentiate normal anatomy </li></ul>
  13. 13. Laboratory Investigation <ul><li>Oral lesions may be manifestations of systemic disease. </li></ul><ul><li>If a systemic disease is suspected it should be pursued. </li></ul>
  14. 14. These include: <ul><li>Tumor of hyperparathyroidism </li></ul><ul><li>Padgets disease </li></ul><ul><li>Multiple myeloma </li></ul><ul><li>Determination of serum calcium, phosphorus, and alkaline phosphatase and protein can be very useful in excluding certain pathological processes. </li></ul>
  15. 15. Indications for Biopsy <ul><li>Any lesion that persists for more than 2 weeks with no apparent etiologic basis </li></ul><ul><li>Any inflammatory lesion that does not respond to local treatment after 10 to 14 days. </li></ul><ul><li>Persistent hyperkeratotic changes in surface tissues. </li></ul><ul><li>Any persistent tumescence, either visible or palpable beneath relatively normal tissue. </li></ul>
  16. 16. Indications for Biopsy <ul><li>Inflammatory changes of unknown cause that persist for long periods </li></ul><ul><li>Lesion that interfere with local function </li></ul><ul><li>Bone lesions not specifically identified by clinical and radiographic findings </li></ul><ul><li>Any lesion that has the characteristics of malignancy </li></ul>
  17. 17. Characteristics of lesions that raise the suspicion of malignancy. <ul><li>Erythroplasia- lesion is totally red or has a speckled red appearance. </li></ul><ul><li>Ulceration- lesion is ulcerated or presents as an ulcer. </li></ul><ul><li>Duration- lesion has persisted for more than two weeks. </li></ul><ul><li>Growth rate - lesion exhibits rapid growth </li></ul><ul><li>Bleeding- lesion bleeds on gentle manipulation </li></ul><ul><li>Induration- lesion and surrounding tissue is firm to the touch </li></ul><ul><li>Fixation- lesion feels attached to adjacent structures </li></ul>
  18. 18. What is a Biopsy? <ul><li>Biopsy is the removal of tissue for the purpose of diagnostic examination. </li></ul>
  19. 19. Types of Biopsy <ul><li>Oral cytology </li></ul><ul><li>Aspiration biopsy </li></ul><ul><li>Incisional biopsy </li></ul><ul><li>Excisional biopsy </li></ul><ul><li>Needle biopsy </li></ul>
  20. 20. Oral Cytology <ul><li>Developed as a diagnostic screening procedure to monitor large tissue areas for dysplastic changes. </li></ul><ul><li>Most frequently used to screen for uterine cervix malignancy </li></ul><ul><li>May be helpful with monitoring postradiation changes, herpes, pemphigus. </li></ul>
  21. 21. The Disadvantage of oral cytological procedures include: <ul><li>Not very reliable with many false positives. </li></ul><ul><li>Expertise in oral cytology is not widely available </li></ul><ul><li>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. </li></ul>
  22. 22. Aspiration Biopsy <ul><li>Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration if its contents. </li></ul><ul><li>Indications: </li></ul><ul><ul><li>To determine the presents of fluid within a lesion </li></ul></ul><ul><ul><li>To a certain the type of fluid within a lesion </li></ul></ul><ul><ul><li>When exploration of an intraosseous lesion is indicated </li></ul></ul>
  23. 23. Aspiration <ul><li>An 18 gauge needle on a 5 or 10 ml syringe is inserted into the area under investigation after anesthesia is obtained. </li></ul><ul><li>The syringe is aspirated and the needle redirected if necessary to find the fluid cavity. </li></ul>
  24. 24. Incisional Biopsy <ul><li>An incisional biopsy is a biopsy that samples only a particular portion or representative part of a lesion. </li></ul><ul><li>If a lesion is large or has different characteristics in various locations more than one area may need to be sampled </li></ul>
  25. 25. Incisional Biopsy <ul><li>Indications: </li></ul><ul><ul><li>Size limitations </li></ul></ul><ul><ul><li>Hazardous location of the lesion </li></ul></ul><ul><ul><li>Great suspicion of malignancy </li></ul></ul><ul><li>Technique: </li></ul><ul><ul><li>Representative areas are biopsied in a wedge fashion. </li></ul></ul><ul><ul><li>Margins should extend into normal tissue on the deep surface. </li></ul></ul><ul><ul><li>Necrotic tissue should be avoided. </li></ul></ul><ul><ul><li>A narrow deep specimen is better than a broad shallow one. </li></ul></ul>
  26. 26. Excisional Biopsy <ul><li>An excisional biposy implies the complete removal of the lesion. </li></ul><ul><li>Indications: </li></ul><ul><ul><li>Should be employed with small lesions. Less than 1cm </li></ul></ul><ul><ul><li>The lesion on clinical exam appears benign. </li></ul></ul><ul><ul><li>When complete excision with a margin of normal tissue is possible without mutilation. </li></ul></ul>
  27. 27. Excisional Biopsy <ul><li>Technique: </li></ul><ul><ul><li>The entire lesion with 2 to 3mm of normal appearing tissue surrounding the lesion is excised if benign. </li></ul></ul>
  28. 28. Principles of Surgery
  29. 29. Anesthesia <ul><li>Block anesthesia is preferred to infiltration </li></ul><ul><li>When blocks are not possible distant infiltration may be used </li></ul><ul><li>Never inject directly into the lesion </li></ul>
  30. 30. Tissue Stabilization <ul><li>Digital stabilization </li></ul><ul><li>Specialized retractors/forceps </li></ul><ul><li>Retraction sutures </li></ul><ul><li>Towel Clips </li></ul>
  31. 31. Hemostasis <ul><li>Suction devices should be avoided </li></ul><ul><li>Gauze compresses are usually adequate </li></ul><ul><li>Gauze wrapped low volume suction may be used if needed </li></ul>
  32. 32. Incisions <ul><li>Incisions should be made with a scalpel. </li></ul><ul><li>They should be converging </li></ul><ul><li>Should extend beyond the suspected depth of the lesion </li></ul><ul><li>They should parallel important structures </li></ul><ul><li>Margins should include 2 to 3mm of normal appearing tissue if the lesion is thought to be benign. </li></ul><ul><li>5mm or more may be necessary with lesions that appear malignant, vascular, pigmented, or have diffuse borders. </li></ul>
  33. 33. Handling of the Tissue Specimen <ul><li>Direct handling of the lesion will expose it to crush injury resulting in alteration the cellular architecture. </li></ul>
  34. 34. Specimen Care <ul><li>The specimen should be immediately placed in 10% formalin solution, and be completely immersed. </li></ul>
  35. 35. Margins of the Biopsy <ul><li>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. </li></ul>
  36. 36. Surgical Closure <ul><li>Primary closure of the wound is usually possible </li></ul><ul><li>Mucosal undermining may be necessary </li></ul><ul><li>Elliptical incision on the hard palate or attached gingiva may be left to heal by secondary intention. </li></ul>
  37. 37. Biopsy Data Sheet <ul><li>A biopsy data sheet should be completed and the specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed. </li></ul>
  38. 38. Intraosseous and Hard Tissue Biopsy <ul><li>Intraosseous lesions are most often the result of problems associated with the dentition. </li></ul>
  39. 39. Indications for Intraosseous Biopsy <ul><li>Any intraosseous lesion that fails to respond to routine treatment of the dentition. </li></ul><ul><li>Any intraosseous lesion that appears unrelated to the dentition. </li></ul>
  40. 40. <ul><li>Palpation of the area of the lesion with comparison to the opposite side. </li></ul><ul><li>Any radiolucent lesion should have an aspiration biopsy performed prior to surgical exploration. </li></ul><ul><ul><li>Information from the aspiration will provide valuable information about the lesion. </li></ul></ul><ul><ul><ul><li>Solid </li></ul></ul></ul><ul><ul><ul><li>Fluid Filled </li></ul></ul></ul><ul><ul><ul><li>Vascular </li></ul></ul></ul><ul><ul><ul><li>Without Contents </li></ul></ul></ul>Clinical Exam
  41. 41. Principles of Surgery <ul><li>Mucperiosteal flaps should be designed to allow adequate access for incisional/excisional biopsy. </li></ul><ul><li>Incisions should be over sound bone </li></ul><ul><li>Cortical perforation must be considered when designing flaps </li></ul><ul><li>Flaps should be full thickness </li></ul><ul><li>Major neurovascular structures should be avoided </li></ul>
  42. 42. Principles of Surgery <ul><li>Osseous windows should be submitted with the specimen </li></ul><ul><li>Osseous preformations can be enlarged to gain access </li></ul><ul><li>Avoid roots and neurovascular structures </li></ul><ul><li>The tissue consistency and nature of the lesion will determine the ease of removal </li></ul>
  43. 43. Principles of Surgery <ul><li>Incisional biopsies only require removal of a section of tissue </li></ul><ul><li>Soft tissue overlying the lesion should be reapproximated following thorough irrigation of the operative site. </li></ul><ul><li>The specimen should be handled as previously described </li></ul>
  44. 44. Biopsy Results: What If ? <ul><li>They don’t corroborate your clinical impression </li></ul><ul><ul><li>Repeat the biopsy!!! </li></ul></ul><ul><ul><li>Determine if the tissue was looked at by an Oral Pathologist </li></ul></ul><ul><ul><li>The results show malignancy </li></ul></ul>
  45. 45. When To Refer For Biopsy <ul><li>When the health of the patient requires special management that the dentist feel unprepared to handle </li></ul><ul><li>The size and surgical difficulty is beyond the level of skill that the dentist feels he/she possesses </li></ul><ul><li>If the dentist is concerned about the possibility of malignancy </li></ul>
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