Differential Diagnosis and Biopsy

1. DIFFERENTIAL DIAGNOSIS AND BIOPSY
Dr. Hadi Munib
Oral and Maxillofacial Surgery Resident

2. OUTLINE
• Examination and Diagnostic Methods
• General Principles of Biopsy
• Surgical Management of Oral Pathologic lesions
• References

4. INTRODUCTION
• Lesions of the oral cavity and perioral areas must be identified and
accurately diagnosed so that appropriate therapy can eliminate the
lesions.
• When abnormal tissue growth is discovered, several important and
orderly steps should be undertaken to identify and characterize it.
• These steps include a comprehensive health history, history of the
identified lesion(s), clinical and radiographic examinations, and relevant
laboratory testing, if indicated.
• Words such as lesion, tumor, growth, and biopsy can carry terrifying
connotations for many patients.

5. EXAMINATION AND DIAGNOSTIC METHODS
• Chief Complaint
• History of the chief complaint
• History of the specific lesion
• Health History
• Dental History
• Social History
• Clinical Examination

6. HISTORY OF THE SPECIFIC LESION
• How long has the lesion been present
• Has the lesion changed in size
• Has the lesion changed in character/ features
• What symptoms are associated with the lesion
• What anatomic locations are involved
• Are there any associated systemic symptoms
• Is there any historical event associated with the onset of the lesion

7. PATHOLOGICAL TERMS

8. DYSPLASTIC FEATURES
• Hyperchromatism
• Hypertrophy
• Hyperkeratosis
• Drop-Shaped Rete Ridges
• Abnormal Stratification
• Increased N/C Ratio
• Enlarged Nucleoli
• Basal Cell Hyperplasia
• Anisocytosis
• Anisonucleosis
• Loss of Polarity
• Increased Number of Mitotic
Figures
• Pleomorphism

11. CLINICAL EXAMINATION
• Anatomic Location of the lesion
• The overall physical characteristics of the lesion
• Single vs. Multiple
• Size, shape and growth presentation of the lesion
• The surface appearance of the lesion
• Lesion coloration
• Sharpness of the lesion borders and mobility

12. CLINICAL EXAMINATION
• Consistency of the lesion to palpation
• Presence of pulsation
• Regional Lymph node examination

15. LYMPH NODES EXAMINATION
• Simple inspection and palpation and comparison of left and right
sides.
• In adults, normal lymph nodes are not palpable, but cervical
nodes of up to 1 cm in diameter can often be palpated in children
up to the age of 12 years.
• 1. Location; 2. Size; 3. Pain Presence; 4. Fixation and 5. Texture.

16. CLINICAL EXAMINATION
• Light- Enhanced Adjuncts for clinical examination:
• At least two low-intensity, blue-and-white light systems are
being marketed as tissue examination adjuncts.
• 490 to 510 nanometers wavelength

17. RADIOGRAPHIC EXAMINATION
• Most pathologic conditions of the mandible or maxilla can be
adequately viewed on routine plain views but specialized imaging
techniques are needed, including CT, CBCT or MRI.
• Pathologic vs. Atypical presentation
• Radiopaque dyes or markers may be used.

19. LABORATORY INVESTIGATIONS
• CBCT
• HbA1c
• Serum Calcium, Phosphate and Alkaline Phosphotase
• Urine Analysis
• Kidney Function Tests
• Tumor Marker Tests

20. DIFFERENTIAL DIAGNOSIS
• Clinical Differential Diagnosis
• Radiographic Differential Diagnosis
• Laboratory Differential Diagnosis

21. BIOPSY

22. PRE-BIOPSY MONITORING
• Any suspicious change in oral tissues that cannot be explained by
localized trauma or other factors should be followed up in 7 to 14
days, with or without local treatment.
• 15% to 20% of Leukoplakias and 100% of Erythroplakia lesions can
exhibit histologic evidence of dysplasia or frank malignancy.
• High-risk areas of the mouth include the floor of the mouth, the
lateral and ventral surfaces of the tongue, and the buccal and lower lip
mucosa.

23. BASIC TENETS OF FOLLOW-UP AND REFERRAL
• Medico-legal issues.
• The referral appointment should ideally be arranged before the patient
leaves the office.
• The General Practitioner can take a biopsy and send it to the laboratory
for testing or refer the patient from the beginning.

24. BIOPSY VS. REFERRAL
• 1. Health of the patient.
• 2. Surgical difficulty.
• 3. Malignant potential.
• The dentist who suspects that a lesion is malignant has two choices:
(1) Perform a surgical biopsy after completion of comprehensive
diagnostic workup
(2) Refer the patient before biopsy is performed to a specialist who is
able to provide definitive treatment if the lesion is shown to be
malignant.

25. GENERAL PRINCIPLES OF BIOPSY
• Removal of tissue from a living body for microscopic diagnostic
examination.
• Biopsy is the most precise and accurate of all diagnostic tissue
procedures.
• The primary purpose of biopsy is to determine the diagnosis
precisely so that proper treatment can be provided
• Incisional, Excisional, Cytological and Aspiration Biopsy

28. ORAL CYTOLOGY – BASED PROCEDURES
• Screening or Follow-up
• Two forms depending on method of collection.
• Exfoliative Cytologic Examination of mucosal cells:
• Most common for uterine cervical cancer.
• Unreliable: Unacceptable false negative results
• Post-Biopsy discomfort

29. • Oral Brush Cytologic Examination
• Imprecisely known as “Biopsy” it’s “Cytologic Examination”
• Collection of epithelial cells
• Rotary Wired Brush
• Noninvasive Examination tool and cheap – Covered in many
insurance plans.
• Doesn’t differentiate between cancerous and precancerous
lesions and sensitivity of 96%.
ORAL CYTOLOGY – BASED PROCEDURES

31. INCISIONAL BIOPSY
• A biopsy procedure that removes only a small portion of a lesion
• >1 cm in diameter
• Located in a risky or hazardous location.
• Differing characteristics in different locations.
• Wedge shaped
• Center vs. sides
• Narrow, Deep Specimen vs. Broad, Shallow Specimen.

34. EXCISIONAL BIOPSY
• Removal of a lesion in its entirety.
• Small lesions
• 2 to 3 mm perimeter of normal tissue around the lesion.
• Complete excision often constitutes definitive treatment

36. ASPIRATION BIOPSY
• A needle and syringe penetrating a suspicious lesion and aspirating
its contents.
• Two main types of aspiration biopsy in clinical practice are:
1. Biopsy to explore whether a lesion contains a fluid.
2. Biopsy to aspirate cells for pathologic diagnosis; Fine-needle
aspiration (FNA).
• FNA is used when a soft tissue mass is detected and the patient
wishes to avoid a scar or adjacent anatomic structures pose a risk.
• Aspiration can be used in all Fluid-Filled cavities except mucoceles.

40. SURGICAL TECHNIQUE OF BIOPSY
• Anesthesia; Block, not into the surgical specimen, at least 1 cm
away.
• Tissue Stabilization
• Hemostasis; Suction and High Volume Suction with a gauze on
the tip
• Incisions
• Wound Closure
• Handling a specimen

41. INSTRUMENTS

42. • The surgical assistant can grasp the lips on both sides of the
biopsy site with his or her fingers, which also retracts and
immobilizes the lips
• Iatrogenic Scalpel Injuries.
• A variety of retractors are available; Towel clips, Adson (fine-tip)
forceps, chalazion forceps, or a heavy retraction suture
• Retraction sutures should be placed deeply into the tissues, away
from the planned biopsy site.
SURGICAL TECHNIQUE OF BIOPSY – TISSUE STABILIZATION

44. SURGICAL TECHNIQUE OF BIOPSY – INCISIONS
• No. 15
• Football shaped incisions
• Laser and Electrosurgical equipment is undesirable
• The size of the ellipse and degree of convergence toward the
base of the lesion depend on the depth of encroachment of the
lesion on normal tissues.
• Palpation may offer clues regarding the depth and expanse of the
submucosal portions of the lesion.

45. SURGICAL TECHNIQUE OF BIOPSY – WOUND CLOSURE
• If the wound is deep, incorporating different tissue layers, deep
closure should be carried out using a resorbable suture material
• In the lips, cheek, floor of mouth, and soft palate, wound margins
are usually undermined in all directions by a distance that is at
least the width of the defect.
• Suture materials: are generally black silk or a nonreactive, slowly
resorbable material such as polyglycolic acid (Dexon) or
polyglactin.

46. HANDLING OF TISSUES – SPECIMEN CARE
• The removed tissue sample should not be wrapped in gauze (wet
or dry).
• The specimen also should be placed immediately on a glass slide
or plastic container that contains a quantity of:
• 10% formalin solution (4% formaldehyde) that is at least 20
times the volume of the specimen itself.
• Suture Tagging.

47. • Biopsy Submission Data Form
HANDLING OF TISSUES – SPECIMEN CARE

48. • A negative (benign) pathology report should never be
taken as a final assessment.
• An experienced clinician put it this way: “Treat the
patient, not the paperwork.”
• If the clinical behavior of a lesion suggests that it is not
benign, a second biopsy of the area should be considered
HANDLING OF TISSUES – SPECIMEN CARE

52. SURGICAL MANAGEMENT OF ORAL
PATHOLOGIC LESIONS

53. BASIC SURGICAL GOALS
• Eradication of pathologic lesion
• Functional Rehabilitation of the patient

54. ENUCLEATION

60. MARSUPIALIZATION

63. • ENUCLEATION AFTER MARSUPILIZATION
• ENUCLEATION AND CURETTAGE

64. RESECTION

66. FACTORS TO CONSIDER
• Aggressiveness of the lesion
• Anatomic Location:
1. Maxilla vs. Mandible
2. Proximity to vital structures
3. Size
4. Intraosseous vs. Extra-osseous
• Duration of the lesion
• Reconstruction Efforts

73. REFERENCES
• Chapter 22: Principles of Differential Diagnosis and Biopsy
• Chapter 23: Surgical Management of Oral Pathological lesions

74. THANK YOU