2. Principles and Techniques ofPrinciples and Techniques of
BiopsyBiopsy
It is important to develop a systematic
approach in evaluating a patient with a
lesion in the Oral and Maxillofacial
region.
3. These steps include :These steps include :
A detailed health history
A history of the specific lesion
A clinical examination
A radiographic examination
Laboratory investigations
Surgical specimens for histopathologic
evaluation
4. Health HistoryHealth History
An accurate health history may disclose predisposing
factors in the disease process or factors that affect the
patients management.
Up to 90% of systemic deseases can be discovered
through history taking.
The same can be true of oral lesions when one is
familiar with the natural progression of the more
common disease processes.
5. Medical conditions thatMedical conditions that
warrant special care include:warrant special care include:
Congenital heart defects
Coagulopathies
Hypertension
Poorly controlled diabetics
Immunocompromised patients
7. Questions to AskQuestions to Ask
Duration of the lesion
Changes in size and rate of change
Changes in the character of the lesion.
– Lump to ulcer, etc
Associated systemic symptoms:
– fever
– nausea
– anorexia
8. More Questions to AskMore Questions to Ask
Pain
Abnormal sensations
Anesthesia
A feeling of swelling
Bad taste or smell
Dysphagia
Swelling or tenderness of adjacent lymph
nodes
Character of the pain if present
9. Historical Reasons for theHistorical Reasons for the
Lesions:Lesions:
Trauma to the area
Recent toothache
Habits
11. Clinical EvaluationClinical Evaluation
The anatomic location of the lesion/mass
The physical character of the lesion/mass
The size and shape of the lesion/mass
Single vs. multiple lesions
The surface of the lesion
The color of the lesion
The sharpness of the boundaries of the lesion
The consistency of the lesion to palpation
Presence of pulsation
Lymph node examination
12. Radiographic ExaminationRadiographic Examination
The radiographic appearance may provide
clues that will help determine the nature of the
lesion.
A radiolucency with sharp borders will often be
a cyst
A ragged radiolucency will often be a more
aggressive lesion
Radiopaque dyes and instruments can help
differentiate normal anatomy
14. These include:These include:
Tumor of hyperparathyroidism
Padgets disease
Multiple myeloma
Determination of serum calcium,
phosphorus, and alkaline phosphatase and
protein can be very useful in excluding
certain pathological processes.
15. Indications for BiopsyIndications for Biopsy
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 to 14 days.
Persistent hyperkeratotic changes in surface
tissues.
Any persistent tumescence, either visible or
palpable beneath relatively normal tissue.
16. Indications for BiopsyIndications for Biopsy
Inflammatory changes of unknown cause that
persist for long periods
Lesion that interfere with local function
Bone lesions not specifically identified by
clinical and radiographic findings
Any lesion that has the characteristics of
malignancy
17. Characteristics of lesions that raise theCharacteristics of lesions that raise the
suspicion of malignancy.suspicion of malignancy.
Erythroplasia- lesion is totally red or has a speckled red
appearance.
Ulceration- lesion is ulcerated or presents as an ulcer.
Duration- lesion has persisted for more than two weeks.
Growth rate- lesion exhibits rapid growth
Bleeding- lesion bleeds on gentle manipulation
Induration- lesion and surrounding tissue is firm to the
touch
Fixation- lesion feels attached to adjacent structures
18. What is a Biopsy?What is a Biopsy?
Biopsy is the removal of tissue for the
purpose of diagnostic examination.
19. Types of BiopsyTypes of Biopsy
Oral cytology
Aspiration biopsy
Incisional biopsy
Excisional biopsy
Needle biopsy
20. Oral CytologyOral Cytology
Developed as a diagnostic screening
procedure to monitor large tissue areas
for dysplastic changes.
Most frequently used to screen for
uterine cervix malignancy
May be helpful with monitoring
postradiation changes, herpes,
pemphigus.
21. The Disadvantage of oral cytologicalThe Disadvantage of oral cytological
procedures include:procedures include:
Not very reliable with many false positives.
Expertise in oral cytology is not widely
available
The lesion is repeatedly scraped with a
moistened tongue depressor or spatula type
instrument. The cells obtained are smeared on
a glass slide and immediately fixed with a
fixative spray or solution.
22. Aspiration BiopsyAspiration Biopsy
Aspiration biopsy is the use of a needle and syringe
to penetrate a lesion for aspiration if its contents.
Indications:
– To determine the presents of fluid within a lesion
– To a certain the type of fluid within a lesion
– When exploration of an intraosseous lesion is
indicated
23. AspirationAspiration
An 18 gauge needle on a 5 or 10 ml
syringe is inserted into the area under
investigation after anesthesia is obtained.
The syringe is aspirated and the needle
redirected if necessary to find the fluid
cavity.
24. Incisional BiopsyIncisional Biopsy
An incisional biopsy is a biopsy that
samples only a particular portion or
representative part of a lesion.
If a lesion is large or has different
characteristics in various locations more
than one area may need to be sampled
25. Incisional BiopsyIncisional Biopsy
Indications:
– Size limitations
– Hazardous location of the lesion
– Great suspicion of malignancy
Technique:
– Representative areas are biopsied in a wedge fashion.
– Margins should extend into normal tissue on the deep
surface.
– Necrotic tissue should be avoided.
– A narrow deep specimen is better than a broad shallow
one.
26. Excisional BiopsyExcisional Biopsy
An excisional biposy implies the complete removal of
the lesion.
Indications:
– Should be employed with small lesions. Less than 1cm
– The lesion on clinical exam appears benign.
– When complete excision with a margin of normal tissue is
possible without mutilation.
29. AnesthesiaAnesthesia
Block anesthesia is preferred to
infiltration
When blocks are not possible distant
infiltration may be used
Never inject directly into the lesion
32. IncisionsIncisions
Incisions should be made with a scalpel.
They should be converging
Should extend beyond the suspected depth of the lesion
They should parallel important structures
Margins should include 2 to 3mm of normal appearing
tissue if the lesion is thought to be benign.
5mm or more may be necessary with lesions that appear
malignant, vascular, pigmented, or have diffuse borders.
33. Handling of the TissueHandling of the Tissue
SpecimenSpecimen
Direct handling of the lesion will expose
it to crush injury resulting in alteration
the cellular architecture.
35. Margins of the BiopsyMargins of the Biopsy
Margins of the tissue should be identified
to orient the pathologist. A silk suture is
often adequate. Illustrations are also
very helpful and should be included.
36. Surgical ClosureSurgical Closure
Primary closure of the wound is usually
possible
Mucosal undermining may be necessary
Elliptical incision on the hard palate or
attached gingiva may be left to heal by
secondary intention.
37. Biopsy Data SheetBiopsy Data Sheet
A biopsy data sheet should be completed
and the specimen immediately labeled.
All pertinent history and descriptions of
the lesion must be conveyed.
38. Intraosseous and Hard TissueIntraosseous and Hard Tissue
BiopsyBiopsy
Intraosseous lesions are most often the
result of problems associated with the
dentition.
39. Indications for IntraosseousIndications for Intraosseous
BiopsyBiopsy
Any intraosseous lesion that fails to
respond to routine treatment of the
dentition.
Any intraosseous lesion that appears
unrelated to the dentition.
40. Palpation of the area of the lesion with comparison
to the opposite side.
Any radiolucent lesion should have an aspiration
biopsy performed prior to surgical exploration.
– Information from the aspiration will provide valuable
information about the lesion.
• Solid
• Fluid Filled
• Vascular
• Without Contents
Clinical ExamClinical Exam
41. Principles of SurgeryPrinciples of Surgery
Mucperiosteal 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
42. Principles of SurgeryPrinciples of Surgery
Osseous windows should be submitted with the
specimen
Osseous preformations can be enlarged to gain
access
Avoid roots and neurovascular structures
The tissue consistency and nature of the lesion will
determine the ease of removal
43. Principles of SurgeryPrinciples of Surgery
Incisional biopsies only require removal of a
section of tissue
Soft tissue overlying the lesion should be
reapproximated following thorough irrigation
of the operative site.
The specimen should be handled as previously
described
44. Biopsy Results: What If ?Biopsy Results: What If ?
They don’t corroborate your clinical impression
– Repeat the biopsy!!!
– Determine if the tissue was looked at by an Oral
Pathologist
– The results show malignancy
45. When To Refer For BiopsyWhen To Refer For Biopsy
When the health of the patient requires special management
that the dentist feel unprepared to handle
The size and surgical difficulty is beyond the level of skill
that the dentist feels he/she possesses
If the dentist is concerned about the possibility of
malignancy