Differential Diagnosis and Biopsy

1. Principles of Differential
Diagnosis and Biopsy
Presenter: Intern 吳景宏
Cover R: 胡育琳 醫師

2. Outline
• Examination and diagnosis methods
• General principles of biopsy
• Soft tissue biopsy techniques and surgical principles
• Intraosseous(hard tissue) biopsy techniques and principles

3. Examination and diagnosis
methods

4. Health History
• Close interrelationship exists between the medical and dental
health of patients and that oral lesions can be a reflection of, or
contributers to, systemic health problems
1) A preexisting medical problem may affect or be affected by
the dentist’s treatment of the patient
2) The lesion may be the oral manifestation of a significant
systemic disease

5. History of the Specific Lesion
1. How long has the lesion been present?
2. Has the lesion changed in size?
3. Has the lesion changed in character or features?
4. What symptoms are associated with the lesion?
5. What anatomic locations are involved?
6. Are there any associated systemic symptoms?
7. Is there any historical event associated with the onset of the lesions?

6. Clinical Examination
• Anatomic location
• Physical characteristics
• Single versus multiple lesion
• Size, shape and growth presentation
• Surface appearance
• Lesion coloration
• Sharpness of border,mobility
• Consistency of the lesion to palpation
• Presence of pulsation

7. Palpation of lymph node

8. Radiographic Examination
• Useful diagnostic adjuncts after completion of the history and clinical
examination, especially for lesions occurring within or adjacent to bone
• Most pathologic conditions can be adequately viewed on routine plain
views (e.g., periapical, occlusal, or panoramic), but occasionally
specialized imaging techniques are needed—including computed
tomography (CT; with the newer cone-beam CT) or magnetic resonance
imaging (MRI) views

9. General
Principles of
Biopsy

10. Incisional Biopsy
Excisional Biopsy
Aspiration Biopsy

13. Incisional Biopsy
• If the lesion is
• large (>1 cm in diameter),
• located in a risky or hazardous location
• whenever a definitive histopathologic diagnosis (e.g., for
suspected malignancy) is desired before planning a complex
removal or other treatment

15. Excisional Biopsy
• Removal of a lesion in its entirety,
to include a 2- to 3-mm perimeter
of normal tissue around the lesion
• For smaller lesions (<1 cm in
diameter)

16. Aspiration Biopsy
1) Biopsy to explore whether a lesion contains a fluid
2) Biopsy to aspirate cells for pathologic diagnosis
• This latter is termed fine-needle aspiration (FNA) (16- to 18-gauge needle)
-ex:Neck masses
3) Routine aspiration of intraosseous R/L lesions

17. Soft Tissue Biopsy Techniques and
Surgical Principles
• Anesthesia
• Tissue Stabilization
• Hemostasis
• Incisions
• Wound Closure

18.  Accurate surgical incisions
can be placed with greater
ease when the involved
tissues are first stabilized

20. Hemostasis
• The assistant can often use gauze sponges to blot the site
• Suctioning can increase not only bleeding but also the risk of
the biopsy tissue sample being accidentally aspirated into the
suction
• If suction is needed, it is helpful to place a gauze pad over the
end of the suction tip to serve as a filter

21. Incisions
• A sharp scalpel, usually with a No. 15 blade
 Football-shaped incision:
- yield an optimal specimen
- easy to close
• The use of laser devices and electrosurgical
equipment for making incisions for biopsies is
not desirable

22. Wound Closure
• Primary closure of the wound is desirable
and usually possible
• Attached mucosal surfaces (e.g., gingiva
and hard palate) are generally not closed
but are allowed to heal by secondary
intention
• Undermining permits tension-free
approximation of tissue margins

23. Intraosseous (Hard Tissue) Biopsy
Techniques and Principles
• The most common intraosseous lesions encountered by the
dentist are periapical granulomas and odontogenic cysts
• Treatment generally involves surgical removal of the lesion by
way of excisional biopsy

24. Intraosseous (Hard Tissue) Biopsy
Techniques and Principles
• When such a lesion is large, perforating into soft tissue overlying
the bone, or where a suspicion of malignancy based on history
and radiographic characteristics exists, incisional biopsy is
indicated

25. Precautionary Aspiration
• Aspiration of all intraosseous lesions should be performed routinely before
opening into the osseous defect to determine whether it contains fluid
• If the cortical plate cannot be penetrated by pressing the needle firmly through
the mucoperiosteum, a flap is reflected and a large round burr is used cautiously
to penetrate

26. Aspiration of intraosseous lesions
straw-
colored
cyst
pus inflammatory or infectious process
air traumatic bone cavity
blood vascular lesion (hemangioma or
arteriovenous malformation)
aneurysmal bone cysts and central
giant cell lesions

27. Mucoperiosteal Flaps
• Most biopsies require an approach through a mucoperiosteal flap
• The choice of flap depends mostly on the size and location of the lesion to be
removed
• Flap should extend 4 to 5 mm beyond the surgical margins of any bony defects
• All mucoperiosteal flaps for biopsies in or on the jaws should be full thickness

31. 歷屆國考試題

32. • 110-1 27.王先生50歲，平日身體硬朗。因為左下舌頭持續三個月的疼痛，合併發
音及吞嚥異常等症狀至醫院就診，臨床檢查發現王先生於左側舌頭舌腹處有約
5×3cm之糜爛性潰瘍。此時最適宜的處理為何？
(A)先給予類固醇塗抹即可
(B)先給予抗生素治療，兩周後再回診，視情況再進行處理
(C).儘快安排切片檢查
(D)先安排吞嚥功能檢查

33. • 110-1 27.王先生50歲，平日身體硬朗。因為左下舌頭持續三個月的疼痛，合併發
音及吞嚥異常等症狀至醫院就診，臨床檢查發現王先生於左側舌頭舌腹處有約
5×3cm之糜爛性潰瘍。此時最適宜的處理為何？
(A)先給予類固醇塗抹即可
(B)先給予抗生素治療，兩周後再回診，視情況再進行處理
(C)儘快安排切片檢查
(D)先安排吞嚥功能檢查

34. • 105-2 28.當牙醫師做抽吸式切片檢查（aspiration biopsy）時，發現針管內吸出的
是血液，可能是下列那一種病變？
(A)multiple myeloma
(B)osteosarcoma
(C).central giant cell granulomas
(D)ameloblastic fibroma

35. • 105-2 28.當牙醫師做抽吸式切片檢查（aspiration biopsy）時，發現針管內吸出的
是血液，可能是下列那一種病變？
(A)multiple myeloma
(B)osteosarcoma
(C)central giant cell granulomas
(D)ameloblastic fibroma

36. • 108-2 23.關於硬組織切片的敘述，下列何者錯誤？
(A)最常見的顎骨內病灶大部分為根尖肉芽腫（periapical granulomas）及齒源性囊
腫（odontogenic cysts）
(B)通常在翻開黏膜瓣後，會先針對骨內病灶做抽吸（needle aspiration），若抽出
來的是單純的透明液體，此病灶極有可能是外傷性骨病灶（traumatic bone lesion）
(C)大部分的骨內病灶，在取組織檢體前，需要用手術骨鑽製造一個骨窗（bone
window）以利我們取樣
(D)儘可能將患者的臨床資料，甚至是放射線影像提供給病理科醫師，可以更有助
於精確的病理診斷

37. • 100-2 15.40歲女士在上唇內側有一大小1公分之病灶，邊界清楚呈圓形，欲確立診
斷，下列何方式最合理？
(A)吸取性活體檢查（aspiration biopsy）
(B)切取性活體檢查（incisional biopsy）
(C)切除性活體檢查（excisional biopsy）
(D)抹片檢查（smear examination）

38. Reference
• Contemporary Oral and Maxillofacial Surgery SEVENTH EDITION

39. Thanks