Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine Al-Azhar University. Oral biopsy; why, when, and how? Biopsy is the removal of the tissue from the living organism for the purpose of microscopic examination and diagnosis. Looking for a definitive diagnosis is the aim of biopsy. Types of Biopsy include incisional, excisional, drill, fine needle and frozen section 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 !!

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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
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