DR JYOTI BISHT MDS DEPT OF ORAL MEDICINE AND RADIOLOGY

1. BIOPSY
Presented by:-
Dr. Jyoti bisht
Dept. of OMR

2. CONTENTS
• Introduction
• Indications & contraindications
• Types of biopsy
• Point to consider prior to biopsy
• Information to accompany oral biopsy
• Interpretation of biopsy report
• Guidelines for appropriate biopsy
• Conclusion

3. INTRODUCTION
Biopsy: Bios – Life, Opsis – Vision
- Biopsy is the removal of small piece of living
tissue for microscopic examination or
analysis & diagnosis.
- The use of biopsy not confined to the
diagnosis , but valuable in determining the
nature of any unusual lesion.

4. HISTORY

5. INDICATIONS
- 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 10-14days .
(i.e. after removing local irritant)
- Persistent hyperkeratotic changes in surface
tissues.
- Bone lesions not specifically identified by clinical
or radiographic findings.

6. - Inflammatory changes of unknown cause, that
persists for long periods.
- Any lesion that has the clinical characteristics of
malignancy.
- To determine the nature of lesion which is
unknown.
- To determine the nature of all abnormal tissue
excised from the oral cavity.

7. CONTRAINDICATIONS
RELATIVE :
Normal Anatomic & Racial variations

8. • Physiological pigmentation

9. Tori and exostosis

10.  Compromised General
health of the patient or a
History Of Bleeding
Disorders, including
patient on Anticoagulant
therapy.
-Proximity of
lesions to Vital
Anatomic Structure
& lesions in areas of
difficult surgical
access.

11.  Pulsative lesions or lesions that
suggestive of a vascular nature.
ABSOLUTE
CONTRAINDICATIONS

12. • Intrabony radiolucent lesions should not
be biopsed or removed without prior
investigational aspiration.
Pigmented lesions should not be biopsed
incisionally.

13. TYPES OF BIOPSY
• Incisional biopsy
• Excisional biopsy
• Aspiration biopsy
• Oral Brush biopsy
• Needle biopsy
• Punch biopsy
• Shave biopsy

14. - Exploratory biopsy
- Curettage biopsy
- Imprint biopsy
- Wedge biopsy
- Electro-surgery biopsy
- Core biopsy
- Cone biopsy
- Endoscopic biopsy
- Liquid biopsy

15. INCISIONAL BIOPSY
- An incisional biopsy is a biopsy that samples
only a particular, or representative part of the
lesion.

16. INDICATIONS
Extensive size (>5
cm in diameter)
If the area under
investigation
appears difficult to
excise.

17.  Lesion in which the diagnosis will determine whether the
treatment should be conservative or radical.
 Whenever there is suspicion of malignancy

18. PRINCIPLES
 Biopsy site should be
selected in an area that
shows complete tissue
changes.
 Necrotic tissue should be
avoided.
 The material should be taken
from the EDGE of the lesion
to include adequate normal
tissue.

19. Take a Deep, Narrow biopsy rather than a broad, shallow
one.

20. TECHNIQUE
Selection of the area to biopsy-
• incisional biopsy performed in the most representative area.
• If there is any doubt about the malignant character of the lesion,
vital staining with toluidine blue can be use.
• •

21. 2. Preparation of the surgical
field
• The surgical area is disinfected - 0.12-
0.20 % chlorhexidine solution is preferred.
Iodine-containing surface antiseptics
should not be used, as they may stain the
tissues.

22. . Local anaesthesia
• Local anaesthetic with vasoconstrictor
[Adrenaline] should be used and infiltrated
away from the lesion to avoid introducing
artefacts in the sample.

23. A clean and defined incision is performed to obtain a slice of tissue.
Soft tissues incisions should be elliptical in shape producing a “V”
wedge that includes both the lesion and healthy margins.

24. EXCISION OF SAMPLE.
COAGULATION FROM GAUZE
PRESSURE

25. TISSUE HANDLING
The specimen is handled gently to avoid crush artefacts and introduced in
the fixing solution.
The role of the fixing agent is to preserve the cellular architecture of the
tissues.
The best fixing agent is a 10% formalin solution, as it induces less
ultrastructural alterations in the samples.
70% ethanol can also be used.

26. - Suture
The suture should achieve good haemostasis, facilitate healing and
should be removed after 6-8 days.
If there is no Non Resorbable Suture than Resorbable Suture can be
used and reviewed 6-8 days after closure.

27. EXCISIONAL BIOPSY
It implies removal of the
entire lesion at the time of
the surgical diagnostic
procedure.
A perimeter of normal
tissue surrounding the
lesion is also excised to
ensure total removal.

28. INDICATIONS
Excisional biopsy should be
employed with smaller lesions
(<5cm in diameter) that on
clinical examination appear to
be benign.

29. PROCEDURE
The entire lesion, along with 2
to 3mm of normal appearing
surrounding tissue, is excised.

33. PUNCH BIOPSY
- Involves a special instrument (PUNCH) for the
removal of a portion of the lesion.
- The punches are composed of a circular blade
or trephine attached to a pencil-like handle.

34. TECHNIQUE
SUSPICIOUS LESION ON
RIGHT LATERAL TONGUE.

35. The edge of the blade of the biopsy punch is placed on the
site and rotated back and forth using moderate pressure to
an appropriate depth until the external bevel is not visible

36. It creates a clearly defined surgical
margin or incision
SPECIMEN REMOVED WITH SCISSORS

37. GAUZE PRESSURE IS
APPLIED TO OBTAIN
COAGULATION
SPECIMEN REMOVED & READY FOR FIXATION

38. - Punch biopsies can remove the entire depth of
lesion, but they are difficult to use in certain
locations, such as where bone is close to the
skin.
- In this method the surgical instrument fills out
small segment of tissue from inaccessible lesion
or from large lesion where excision is
contraindicated.

39. ASPIRATION BIOPSY
Aspiration biopsy is the use of a needle & syringe to
penertrate a lesion for aspiration of its content.

40. INDICATIONS
• In all lesions thought to contain
fluid or any intraosseous lesion
before surgical exploration.
• A fluctuant mass in the soft
tissues to determine its contents.

41. • Any radiolucency in the bone of the jaw
should be aspirated to rule out a vascular
lesion.

42. - A sample of tissue is obtained by passing a
needle into the suspected mass.
-
- Suction is then produced in the syringe &
the needle is moved back & forth rapidly
in the tissue.
- Small shavings of tissue are obtained in the
barrel of the syringe that are later fixed on a
slide & examined under microscope.
TECHNIQUE

43. ASPIRATION TECHNIQUE
SWELLING IN THE NECK ASPIRATION OF FLUID

44. PREPARING A SMEAR OF ASPIRATE
PRIOR TO STAINING.

45. ORAL EXFOLIATIVE CYTOLOGY
- Exfoliative cytology is the
microscopic examination of shed
cells from an epithelial surface.
- Rapid, Non Invasive Procedure,
which is valuable in screening
patients with oral lesions.

46. INDICATIONS
- Periodic review of Oral Premalignant Lesions &
Oral Cancer Patients.
- Population screening of oral lesions.
- When biopsy is contraindicated on medical grounds.
- In the diagnosis of lesions e.g Herpes simplex
infection, Herpes Zoster, Pemphigus vulgaris,
White sponge nevus.
- In patient who refuse biopsy

47. ARMAMENTARIUM
- Glass slides
- Cytobrush (if there is more than one lesion, then
1 Cytobrush per lesion) or wooden/ steel
spatula.
- Cotton, gauze,mouthmirror &probe

48. - With a gauze gently remove any excess
saliva in the area that will be smeared.
- Vigorously scrape & rotate the Cytobrush
over the entire lesion.
- Scraping should not be painful to the patient
but it should be vigorous enough so that it is
noticeable & may generate a small amount
of bleeding.
- Take the Cytobrush & spread the harvested
cells onto the glass slide.
TECHNIQUE

50. ADVANTAGES
- Non invasive & easy to perform.
- Requires no specialized instruments .
- Can be used to note the progress of treatment &
regression of lesion.
- Repeated smears can be taken.
- Early diagnosis of cancer.
- No problem of wound healing.

51. DISADVANTAGES
- Acts only as a supportive diagnostic aid & acts
as an adjuvant to biopsy.
- Definitive diagnosis is not possible
- Does not help in diagnosing the depth of the
lesion.
- Inflammatory lesions may be misdiagnosed as
malignancy.

52. ORAL BRUSH BIOPSY
Components of kits
– Oral brush biopsy
instrument
– Precoded glass slide &
matching coded test
requisition form
– Alcohol / carbowax fixative
pouch
– Preaddressed container for
submitting the contents

53. BRUSH BIOPSY INSTRUMENT
• The brush is sterile.
• One OralCDx test kit
• Brush is designed to penetrate to the basement
membrane & thus achieve a complete
transepithelial specimen.

54. Unlike cytology instruments which collect only superficial cells,
the biopsy brush obtains cells from all three epithelial layers of
the oral mucosa: Superficial, Intermediate & Basal.

55. INDICATIONS
Epithelial abnormalities
– Leukoplakia, Erythroplakia, Chronic Ulcerations,
Mucosa That Is Atrophic, Thickened, Traumatized
CONTRAINDICATIONS
Lesions with Intact Normal Epithelium
– Fibromas, Mucoceles, Hemangiomas, Submucosal
Masses, Pigmented Lesions, Amalgam Tattoos
– Highly suspicious lesions

56. COLLECTION OF
SAMPLE

57. TRANSFERING CELLS TO SLIDE FIXING CELLS TO SLIDE USING
ALCOHOL/POLYETHYLENE GLYCOL
FIXATIVE

58. EXAMINATION OF CELLS USING COMPUTER

60. ORALCDX RESULTS
“INADEQUATE”: Re-test
“NEGATIVE”: No Cellular Abnormalities
“POSITIVE”: Definitive Cellular Evidence of
Epithelial Dysplasia Or Carcinoma
“ATYPICAL”: Abnormal Epithelial changes
warranting Further Investigation

61. SHAVE BIOPSY
• Best for raised lesions
mostly confined to the
epidermis
– benign nevi
– small nodular basal cell
carcinomas
• Not for suspected
melanoma

62. SHAVE BIOPSY STEPS
The most commonly performed shave biopsy technique employs a No. 15 scalpel
blade.
Stretch and stabilize the skin with your nondominant hand , hold the scalpel blade
horizontal to the skin, and insert it just outside the periphery of the lesion. Whenever
possible, use a single, smooth cutting stroke..

63. HEMOSTASIS WITH
ALUMINUM CHLORIDE

64. INDICATIONS
• Diagnosis of :
– Nodular basal cell carcinomas
– Squamous cell carcinoma
– Actinic keratosis
CONTRAINDICATIONS
– Melanoma
– Pigmented lesion highly
suspicious for melanoma

65. ELECTRO-SURGERY BIOPSY
- Refers to the cutting & coagulation of tissue using
very high-frequency, low-voltage electrical currents.
- A blended current combines cutting & coagulation,
& is useful in producing a bloodless operative field.
- Lesion excisions on the face are usually performed
with only a cutting current to limit scarring at the
wound base, which can be produced by the effects
of thermal coagulation.

66. TECHNIQUE
The lesion is
Grasped with
forceps through the
loop electrode. The
electrode is activated
going under the
lesion, removing the
growth.

67. EXPLORATORY BIOPSY
It is done for the investigations of an
internal lesion.
In this removal of all portion of tissue
expose is done.
This is commonly employed for the intra
osseous lesions of mandible &maxilla.

68. CURETTAGE BIOPSY
- Used primarily for Intra Osseous Lesions & very
friable cellular lesions, where only small
amounts of surface material are necessary for
evaluation.
- Extremely small tissues are centrifuged &
sedimentary segments are placed in Agar media
and then sectioned as tissue blocks.
- Used successfully on lesions like actinic
keratosis, superficial SCC & BCC & Warts.

69. IMPRINT CYTOLOGY
- In this technique , the biopsed tissue is cut into
two halves and the cut surface is touched to
the slide.
- Slide is stained later to see the exfoliated cells.
- Imprint cytology of biopsed tissue could be used
to provide a rapid preliminary diagnosis.
- Imprint cytology of a biopsy can be reported
within an hour.

70. ARMAMENTARIUM FOR BIOPSY
- Mouth mirror, probe, antiseptic
agent.
- Local anaesthetic agent &
syringe,B.P blade no. 15.
- Surgical scissors & tissue forceps
- Bone curette, small hemostat.
- 10%neutral buffered formalin.
- Sterile saline irrigation.

71. INFORMATION TO ACCOMPANY
MUCOSAL BIOPSIES
1. Patient demographic data
2. Description of the clinical appearance of the lesion &
suspected diagnosis
3. Site of the biopsy-An explanatory diagram of the biopsy area
may be useful for this purpose.
4. Relationship of the lesion to restorations, particularly amalgam
5. Detailed Drug history
6. Medical history including blood disorders
7. Smoking & alcohol consumption

72. PRINCIPLES OF SURGERY
• Mucoperiosteal 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.

73. INCISION
- Sharp scalpel should be used to incise
tissue for routine conventional biopsy.
- Two incisions forming an ellipse at the
surface & converging a V at the base of
the lesion provide a good specimen &
leave a wound that is easy to close.
- Thin, deep specimens are preferable to
broad, shallow specimens.
- A periphery of the normal appearing
tissue should be included in both
Incisional & excisional biopsy
specimens.

74. IDENTIFICATION OF SURGICAL MARGIN
Margins of the biopsy specimen should be marked
with a silk suture to orient the specimen to the pathologist.
SPECIMEN CARE
After removal, the tissue should be immediately placed
in 10% formalin solution, at least 20 times the volume
of the surgical specimen.
- Specimens should be placed in wide opened bottle.
- Leakage of the formalin should be prevented.

75. COMPLICATIONS OF
ORAL BIOPSY
- Hemorrhage
- Infection
- Poor wound healing
- Spread of Tumour cells
- Injury to adjacent tissues
- Reactions to local anesthetics

76. GUIDELINES FOR AN
APPROPRIATE BIOPSY
• Chronic ulcer or
Squamous cell
carcinoma.
Incisional biopsy

77. • Mucosal Lichen
Planus
Incisional biopsy
punch biosy of a
representative area.

78. Leukoplakia/
Erythroplakia
Incisional or Punch
biopsy of worst area.
Consider multiple
biopsies if extensive
lesion.

79. Bullous lesions
(Pemphigus,
Pemphigoid etc)
mucosa close to bulla
or erosion plus fresh
tissue specimen.

80. Mucocoele Careful excision
biopsy

81. • Pyogenic granuloma,
Epulis
Excision biopsy

82. • Minor salivary gland
tumour
PALATE: deep
Incisional biopsy
UPPER LIP:
Excisional biopsy

83. Major salivary gland
tumour
FNAC

84. CONCLUSION
• Biopsies are important diagnostic tool
for diagnosis of lesions ranging from
simple periapical lesions to malignancies.
• Planning prior to performing a biopsy is
essential . It will be beneficial to the receiving
pathologist in reaching a helpful & meaningful
diagnosis.

85. REFERENCES
• Textbook Of Oral Pathology
- SHAFER, HINE, LEVY(5TH ED.)
• Textbook Of Oral & Maxillofacial Pathology
- MARX.E.STERN (2ND ED.)
• Oral Mucosal Biopsy Procedures
- DCNA, 94 (38) 279-300.
• Brush Biopsy ‘Saves Life’
- JADA,2002 (133) 688-689.
• Oral Cancer
- SILVERMAN (2ND ED.)