The document provides guidelines for oral biopsies, including definitions, types of biopsies (excisional, incisional, punch, aspiration, brush biopsy), indications and contraindications. It discusses principles of biopsy including obtaining adequate tissue and margins. Information to include with biopsy specimens and interpreting biopsy reports is also outlined. Complications and appropriate use of biopsies for diagnosing conditions like cancer or leukoplakia are summarized. The document provides an overview of performing and evaluating oral biopsies.

1. GOOD MORNING

2. BIOPSY
Presented by:-
Dr. Ashish Aggarwal
1st
.yr PG student
Dept. of OMDR

3. 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

4. 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
of tumor, but valuable in determining the nature
of any unusual lesion.

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 variation such as
Physiologic pigmentation, Leukoedema, linea
Alba, tori, exostosis & others.
 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.

8.  Pulsative lesions or lesions that
suggestive of a vascular nature.
 Intrabony radiolucent lesions
should not be biopsed or removed
without prior investigational
aspiration.
 Pigmented lesions should not be
biopsed incisionally.
ABSOLUTE
CONTRAINDICATIONS

9. TYPESOF BIOPSY
• Excisional biopsy
• Incisional biopsy
• Oral Brush biopsy
• Aspiration biopsy
• Needle biopsy
• Punch biopsy
• Shave biopsy

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

11. INCISIONAL BIOPSY
- An incisional biopsy is a biopsy that samples
only a particular, or representative part of the
lesion.
- If the lesion is large or has different characteristics
at different locations, more than one area of the
lesion may need to be sampled.

12. INDICATIONS
Extensive size (>5 cm in diameter)
 If the area under investigation appears difficult to
excise.
 Lesion in which the diagnosis will determine
whether the treatment should be conservative
or radical.
 Whenever there is suspicion of malignancy.

13. INCISION USING CONVENTIONAL SCALPEL
EXCISION OF SAMPLE.

14. COAGULATION FROM GAUZE PRESSURE.
SPECIMEN PLACED IN 10% BUFFERED FORMALIN

15. 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.
 Take a Deep, Narrow biopsy rather than a broad,
shallow one.

16. 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.

17. INDICATIONS
Excisional biopsy should be
employed with smaller lesions
(<5cm in diameter) that on
clinical examination appear to
be benign.
PROCEDURE
The entire lesion, along with 2
to 3mm of normal appearing
surrounding tissue, is excised.

18. PUNCHBIOPSY
- 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.
- The instrument is gently rotated with firm
downward pressure. The punch is pushed down
until the subcutaneous fat is reached.

19. SUSPICIOUS LESION,
RIGHT LATERAL TONGUE.
AREA STAINED WITH TOLUIDINE BLUE. 5 MM PUNCH

20. INCISION MADE
SPECIMEN REMOVED WITH SCISSORS

21. COAGULATION OBTAINED WITHIN
MINUTES BY GAUZE PRESSURE.
SPECIMEN REMOVED & READY FOR FIXATION

22. - 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.

23. ASPIRATION BIOPSY
Aspiration biopsy is the use of a needle & syringe to
penertrate a lesion for aspiration of its content.
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.
• Any radiolucency in the bone of the jaw should be
aspirated to rule out a vascular lesion.

24. - 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

25. ASPIRATION TECHNIQUE
SWELLING IN THE NECK ASPIRATION OF FLUID

26. PREPARING A SMEAR OF ASPIRATE
PRIOR TO STAINING.

27. 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.

28. 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

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

30. - 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

32. 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.

33. 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.

34. 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

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

37. 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

38. COLLECTION OF
SAMPLE

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

40. EXAMINATION OF CELLS USING COMPUTER

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

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

44. SHAVE BIOPSY STEPS

45. HEMOSTASIS WITH
ALUMINUM CHLORIDE

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

47. 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.

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

49. 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.

50. 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.

51. 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.

52. ARMAMENTARIUMFORBIOPSY
- 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.

53. POINTS TO CONSIDER PRIOR
TO BIOPSY
1. WHY IS BIOPSY BEING TAKEN?
Eg to confirm a mucosal disease such
as lichen planus or to exclude malignancy.
2. WHAT INFORMATION IS REQUIRED FROM
THE PATHOLOGIST?
Eg is the lesion completely excised?

54. 3. IS THE BIOPSY TO EXCLUDE MALIGNANCY?
Therefore take the biopsy from the edge
of the lesion.
4. IS THE BIOPSY INCISIONAL OR EXCISIONAL?
Eg For excisional biopsies a margin of
surrounding normal tissue will be required.
5. IS A FRESH SPECIMEN REQUIRED?
For vesiculobullous lesions these are often
required for direct immunofluorescence.
They are also used if a rapid diagnosis.

55. 6. WILL THE SPECIMEN BE REQUIRED TO BE
ORIENTATED?
This is important for excisional biopsies so that
if residual tumour is left or the excision is close
to the margin, the surgeon knows where to
perform a re-excision if necessary.

56. 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
4. Relationship of the lesion to restorations,
particularly amalgam
5. Detailed Drug history
6. Medical history including blood dyscrasias
7. Smoking & alcohol consumption

57. 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.

58. INCISION
- Sharp scalpel should be used 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.

59. 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.

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

61. INTERPRETING ORAL&MAXILLOFACIAL
BIOPSY REPORTS
1. PATIENT INFORMATION
- Patient’s age, gender & race.
- Pathology record number & the name of the
ordering clinician.
2. LOCATION OF LESIONS
- The exact location of all lesions.

62. 3. CLINICAL NOTES
- A summary of the clinical history provided by
clinician.
- Description of the clinical appearance should be
reported as well as any significant symptoms &
associated duration.
- Radiographic features, surgical findings & the
type of surgical procedure performed should also
be included.
- Also included is the differential diagnosis &
clinical impression of the submitting doctor.

63. - Represents a pathologist’s macroscopic
evaluation & description of the specimen
received.
- Include how the specimen container was
labeled,the fixative used & the orientation of
the specimen.
- Pathologist also describe whether the entire
specimen was submitted for processing or only
a representative sample.
GROSS DESCRIPTION

64. 5.. MICROSCOPIC DESCRIPTION
- Describes the salient microscopic features that
led to the establishment of a histologic diagnosis.
6. DIAGNOSIS
- Most important part of the pathology report.
It typically includes a final diagnosis along with the
specific anatomic location.
- A diagnosis may be definitive (e.g. ameloblastoma)
or, if the microscopic & clinical findings are
nonspecific, a descriptive diagnosis may be given.
(e.g. acute & chronic inflammation).

65. FINAL DIAGNOSIS
• Should correspond to the clinical course before
& after biopsy.
• A negative pathology report for malignancy
should not lull the dentist into a false sense of
security when the clinical characteristics of the
lesion still indicate malignant potential.

66. FINAL DIAGNOSIS
• If the pathology report does not
corroborate the clinical impression of the
lesion, the biopsy procedure should be
repeated.

67. GUIDELINES FOR AN
APPROPRIATE BIOPSY
• Chronic ulcer or
Squamous cell
carcinoma.
• Leukoplakia/
Erythroplakia
Incisional biopsy
Incisional or Punch
biopsy of worst area.
Consider multiple
biopsies if extensive
lesion.

68. • Mucosal Lichen
Planus
• Bullous lesions
(Pemphigus,
Pemphigoid etc)
• Mucocoele
Incisional biopsy of a
representative area.
Incisional or Punch
biopsy of unaffected
mucosa close to bulla
or erosion plus fresh
tissue specimen.
Careful excision
biopsy

69. • Pyogenic granuloma,
Epulis
• Minor salivary gland
tumour
• Major salivary gland
tumour
Excision biopsy
PALATE: deep
Incisional biopsy
UPPER LIP:
Excisional biopsy
FNAC

70. 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.

71. THANK YOU

72. 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.)