The_histological_observation_of_laser_biopsy.18.pdf

1. © 2022 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow 299
Case Report
Address for
correspondence:
Dr. Lakshmiganthan
Mahalingam,
Department of
Periodontics, Karpaga
Vinayaga Institute
of Dental Sciences,
Chinna kolambakkam,
Chengalpattu,
Tamil Nadu, India.
E‑mail: drlakshmiganth@
gmail.com
Submitted: 06‑May‑2021
Revised: 06‑Sep‑2021
Accepted: 28‑Nov‑2021
Published: 02-May-2022
Department of
Periodontics, Karpaga
Vinayaga Institute
of Dental Sciences,
Chengalpattu, Tamil
Nadu, India
The work belongs to
the Department of
Periodontics Karpaga
Vinayaga Institute
of Dental Sciences,
Chengalpattu,
Tamilnadu, India
The histological observation of laser
biopsy versus scalpel biopsy on plasma
cell gingivitis
Lakshmiganthan Mahalingam
Abstract:
Biopsy is one of the histological diagnostic techniques used to assess cells and tissues to determine the presence
and extent of a simple nonneoplastic growth to complicated malignancies. In the oral cavity, there are many
techniques available to harvest the tissue, it depends on anatomical location and morphology of the lesion. In
which many causes artifacts in the specimen due to poor technique and handling, which can lead to diagnostic
pitfalls and misery. Laser is one of the advanced surgical tools used to harvest oral tissue with minimal anesthesia
and less discomfort. This was a split‑mouth case report conducted on smaller lesion (plasma cell gingivitis) to
assess laser and scalpel surgical techniques to determine thermal damage of laser biopsy.
Key words:
Biopsy, laser, scalpel
INTRODUCTION
Oral biopsy is a surgical procedure used
to harvest tissue from the oral cavity to
determine the histological characteristics of a
lesion. In which differentiation, extent or spread
of the lesion, and final decision on treatment
were determined.[1]
Biopsy is a critical diagnostic
tool used for suspicious malignancy of enlarged
induratedmass,chroniculceration,andpersistent
mucosal lesion. Benign and malignant lesions
from the oral cavity are originating from the oral
mucosa that is covered by stratified squamous
epithelium.[2]
The biopsy must have clear and
readable epithelium and connective tissue to
make an unequivocal histological diagnosis. The
most widely used and gold standard technique
to harvest the tissue was scalpel, because it is
easy to harvest and it has accuracy, but it can
also cause profuse bleeding that obscures the
operative field.[3]
In the past two decades, laser
was the most commonly used device in dentistry
for surgical and nonsurgical procedures, and it
was also proved easy to use, efficient, specific,
comfortable, and cost‑effective,[4,5]
but it also
has a disadvantage of thermal and mechanical
damages to the biopsy and surgical site.[3]
Plasma cell gingivitis is a rare unique disorder
which was first described in late 1960.[6]
It is
clinically characterized by painful, ulcerated,
edematous lesion, and tendency to spontaneous
bleeding. Histopathologically, it appears
dense and massive plasma cell infiltration into
subepithelial connective tissue and it also mimics
like life‑threatening entities such as squamous
cell carcinoma, autoimmune mucocutaneous
bullous diseases, and lymphoproliferative
disorders. It was also associated with some
infectious diseases such as syphilis, Castleman’s
disease, primary infectious disease of the lymph
node, and recently COVID‑19.[7]
This was a split‑mouth case report conducted
on plasma cell gingivitis (smaller lesion)
to observe difference in histopathological
changes on excisional biopsy using the
laser (diode) and scalpel surgical technique
on the same patient.
CASE REPORT
A 38 year old female patient reported to the
Department of Periodontics, Karpaga Vinayaga
Institute of Dental Sciences, chengalpattu,
Tamilnadu, India, the chief complaint of the
patient was swelling and bleeding in the gums
for the past 2 months. The medical history was
How to cite this article: Mahalingam L. The
histological observation of laser biopsy versus
scalpel biopsy on plasma cell gingivitis. J Indian
Soc Periodontol 2022;26:299-301.
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DOI:
10.4103/jisp.jisp_292_21
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2. Mahalingam: Laser versus scalpel biopsy
300 Journal of Indian Society of Periodontology - Volume 26, Issue 3, May-June 2022
Figure 2: Laser biopsy shows loss of epithelium (A); with plasma cells
infiltration (B)
Figure 4: Laser on day 30 healing site. Thickened epithelium (A); with rich blood
vessels (B)
Figure 3: Scalpel on day 30 healing site. Thinned epithelium (A); with minimal
blood vessels (B)
noncontributory and hemogram reports were normal. On
examination, marginal gingiva and interdental papilla on the
labial aspect of the maxillary anterior region in relation to
tooth numbers 11, 12, and 21 appeared reddish, enlarged and
extended into the attached gingiva. The lesion was painless,
soft, and bleeds on palpation, and part of treatment oral
prophylaxis was done, and the patient was asked to report
after 2 weeks for review. On review of the patient, there was no
recovery of the lesion and provisionally diagnosed as plasma
cell gingivitis. Patient consent form obtained and planned
for excisional biopsy with scalpel in tooth number 11, 12 and
diode laser in tooth number 21 and patient asked to report after
1 month for review. Scalpel biopsy specimen [Figure 1] showed
stratified squamous epithelium with underlying connective
tissue densely infiltrated with plasma cells. Laser biopsy
specimen [Figure 2] showed loss of epithelium with underlying
connective tissue densely infiltrated with plasma cells.
Postoperative review on day 30, the lesion was subsided, and
histological healing was assessed on both scalpel and laser
surgical sites. The postsurgical healing site specimen with
scalpel [Figure 3] showed thinned epithelium with fewer blood
vessels and with laser [Figure 4] showed thickened epithelium
with numerous blood vessels.
DISCUSSION
Oral biopsy is a critical diagnostic aid when the lesions cannot
be diagnosed based on history and clinical examination.[8]
It
is helpful to establish a definitive diagnosis and prognosis on
premalignant or malignant lesions and make sure the lesion has
been completely removed.[9]
Oral biopsies can be taken in many
techniques, whatever the method, the ultimate goal is to give
typical sample to the pathologist for interpretation and provide
perioperative comfort to patients. In case a defective sample of
specimen can make faulty diagnosis leads to treatment failure
and recurrence of the lesion.[10]
Traditionally, the scalpel has been considered the gold standard
technique because of its precision control and preservation
of tissue integrity. Later, laser was proven to be easy to use,
efficient, cost‑effective, and produce heat during a procedure
causes drying, vaporization, and carbonization that leads to
protein denaturation and coagulation at the surgical site, this
seals the blood vessels and inhibits pain receptors that reduces
pain and inflammation, and it also disinfects the surgical site
and improves wound healing.[3]
In the present case report, biopsy was compared between
laser and scalpel surgical techniques on plasma cell gingivitis
of the same patient. For laser surgical technique, Diode
Laser was used at wavelength of 810 nm in pulsed mode
Figure 1: Scalpel biopsy shows stratified squamous epithelium (A); with plasma
cells infiltration (B)

3. Mahalingam: Laser versus scalpel biopsy
Journal of Indian Society of Periodontology - Volume 26, Issue 3, May-June 2022 301
with 200 µm fiber and output power of 3.5W CW, it causes
minimal bleeding with more surgical time, in scalpel surgery,
there was profuse bleeding with less surgical time was taken,
and the patient was comfortable in both laser and scalpel
surgeries. Histopathological results of laser specimen showed
loss of epithelium, loss of margin of connective tissue, and the
remaining connective tissue infiltrated with plasma cells. In
scalpel specimen, epithelium was intact and connective tissue
was infiltrated with plasma cells. On postoperative day 30, laser
biopsy specimen showed thickened epithelium with numerous
blood vessels in connective tissue, and in scalpel specimen
showed thinned epithelium with few blood vessels in surgical
site, postoperative healing was good with laser.
Yanduri conducted a study on laser versus scalpel biopsy
technique in the oral lesion and reported that laser has an
advantage of providing hemostasis during surgery compared
to scalpel. On the other hand, overheat was produced by the
laser can cause damage to the epithelium and connective
tissue (fulguration artifact). A specimen with fulguration
artifact is associated with epithelial loss, and it also affects the
nuclei of cells causes spindled, palisading, and hyperchromatic
nuclei. This change can mimic the appearance of epithelial
dysplasia and lead to an incorrect histopathological diagnosis,
it occurs especially at the margins, which are extremely
important for the clinician in terms of the presence/absence of
dysplasia and invasion. Finally, he stated that the use of a laser
should be limited to excisional biopsies with relatively large
sample size where the adequate margin is available and used
with low power laser, which was effectively decrease the risk
of separating the epithelium from the basement membrane.[1]
Bhatsange also reported that laser produces thermal artifacts
that may interfere with histologic interpretation of the lesion
and it should be used with caution for diagnostic biopsy or
when information from the margins is required.[3]
The presence or absence of epithelium in conditions such
as epithelial dysplasia and epithelial invasion is extremely
important in the histopathological evaluation of premalignant
and malignant lesions. One of the major disadvantages of laser
in biopsy with respect to the damage occurs at the margins of
the lesion.[1]
This laser‑tissue interaction at the margins may
produce some artifactual changes, such as thermal damage
and coagulation which may impair the histopathological
diagnosis.[2]
CONCLUSION
Biopsy is a vital tool to diagnose oral mucosal lesion, although
many techniques exist to harvest biopsy specimen, the
ultimate goal is to obtain an ideal tissue sample to facilitate
histopathological interpretation. Laser although provide
good operative field with wound healing should be cautious
on smaller lesion due to marginal damage of the biopsy
specimen, because many of the oral lesions originated from
oral epithelium.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not be
published and due efforts will be made to conceal their identity,
but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Yanduri S, Pandey G, Kumar VB, Suma S, Madhura MG. Artifacts
in oral biopsy specimens: A comparison of scalpel, punch and
laser biopsies. Indian J Oral Health Res 2016;2:100‑5.
2. Avon SL, Klieb HB. Oral soft‑tissue biopsy: An overview. J Can
Dent Assoc 2012;78:c75.
3. Bhatsange A, Meshram EP, Waghamare A, Shiggaon L,
Mehetre V, Shende A. A clinical and histological comparison of
mucosal incisions produced by scalpel, electrocautery and diode
laser: A pilot study. J Dent Lasers 2016;10:37‑42.
4. Verma SK, Maheshwari S, Singh RK, Chaudhari PK. Laser in
dentistry: An innovative tool in modern dental practice. Natl J
Maxillofac Surg 2012;3:124‑32.
5. Patton LL, Epstein JB, Kerr AR. Adjunctive techniques for oral
cancer examination and lesion diagnosis: A systematic review of
the literature. J Am Dent Assoc 2008;139:896‑905.
6. Negi BS, Kumar NR, Haris PS, Yogesh JA, Vijayalakshmi C,
James J. Plasma‑cell gingivitis a challenge to the oral physician.
Contemp Clin Dent 2019;10:565‑70.
7. Leuci S, Coppola N, Adamo N, Bizzoca ME, Russo D,
Spagnuolo G, et al. Clinico‑pathological profile and outcomes of
45 cases of plasma cell gingivitis. J Clin Med 2021;10:830.
8. Funde S, Dixit MB, Pimpale SK. Comparison between laser,
electrocautery and scalpel in the treatment of druginduced
gingival overgrowth: A case report. IJSS Case Rep Rev
2015;1:27-30.
9. Sciubba JJ. Oral cancer. The importance of early diagnosis and
treatment. Am J Clin Dermatol 2001;2:239‑51.
10. Oliver RJ, Sloan P, Pemberton MN. Oral biopsies: Methods and
applications. Br Dent J 2004;196:329‑33.