Oral Biopsy

‫ عبد العزيز‬/‫ د‬2019/12/17 ‫) للفرقة الثالثة بتاريخ‬Diagnosis( 12 ‫املحاضرة الـ‬

Lecture outlines:

 Definition of Biopsy.
 Timing of biopsy.
 Indications.
 Characters of lesions that rise subsection of malignancy.
 Steps taken before biopsy.
 Medical conditions that warrant special care.
 How to take a biopsy.
 Contraindication of biopsy.
 General principles of oral biopsy.
 Rules.
 Types of biopsy:
1- Excisional.
2- Incisional.
3- Aspiration.
4- Punch.
5- Drill.
6- Exfoliative cytology.
 Vital stains.
 Fine needle aspiration biopsy
 Drill biopsy
 Frozen sections.

3L for proper diagnosis

1. Listen
2. Look
3. Locate

Most dangerous lesions present in:

1. Floor of the mouth (most dangerous one)
2. Lateral surface of the tongue
3. Soft palate
. cells ‫يبق فيه مشكلة ى يف ال‬
‫ ى‬keratinization ‫معن ان يحصل فيهم‬
‫ ف ى‬lining mucosa ‫ألن دول‬

1|P a g e
Definition: Biopsy (Greek word) = bios (life) + opsis (vision)
 Is the removal of tissues (not cut as some types do not need a cut but aspiration or scrapping)
from the living body for the purpose of microscopic examination & reach a diagnosis.

 Timing of biopsy: (preoperative – intraoperative – postoperative). (Oral Q)

Why do I take a biopsy?

 To reach a diagnosis, to confirm the diagnosis of suspected malignant lesions, precancerous
Lesion may be leukoplakia (white lesion), erythroplakia (red, erythematous, macular lesion),
chronic ulceration of unknown cause & is recommended for apparently inflammatory lesions
that do not improve within 2 weeks after removal of local irritation.

 Other lesions should also be biopsied (why?):

▪ Lesions that interfere with oral function, such as fibrous hyperplasia and osseous lumps.
▪ Lesions of unclear etiology, particularly when associated with pain anesthesia or paresthesia.
▪ Exophytic (as granuloma) or other lesions.
▪ Radiolucent or radiopaque osseous lesions biopsy is indicated for histological confirmation of
certain systemic disorder.
▪ If you see erythroplakia, you may think it is inflammation, but don’t think like this. Erythroplakia: elevated above
▪ Red lesions especially in lateral surface of the tongue or floor the surface
of the mouth, you have to suspect something wrong and you Erythroplasia: with the surface
must take the precaution, in this case biopsy helps in early
diagnosis of malignant lesions do treatment is done immediately and follow up.

- To take biopsy, you must take good history and lesion must N. B - Parotid gland biopsy is by
be well described because lesion may be connected with aspiration as it’s well capsulated
any information from history.

 Indications (Why):
1. When careful examination fails to reach a diagnosis.
2. To recognize pre-cancerous lesions.
3. Lesions with clinical signs of malignancy.
4. Lesions not respond to therapy.
5. For differential diagnosis.
6. As a general rule: when there is doubt do biopsy.
7. Confirming the diagnosis or differentiate the similar diseases.
8. If there is any inflammation persists for long time with unknown cause.
9. Lesion appears with no local factor.
10. Bone lesion not identified by examination.
11. Any lesion, when malignant changes appear on it.

 Steps taken before biopsy:

1. Detailed health history
2. History of specific lesion (indurated or not - margins-areas surrounding if erythematous this
may be inflammation and if not, this may be a white lesion)
3. Clinical examination
Before biopsy is done, patient written
4. Radiographic examination consent should be taken and to inform
5. Laboratory investigations the patient what u will do &
6. Surgical specimen for Histopathological evaluation complications that may occur

2|P a g e
Notes:
- By experience, you will know specific criteria with it you will know that, the lesion has changes into malignant as in leukoplakia,
instead of being white it will be widely opaque or white lesion changes to ulcer or erosion or fissuring or white lesion with lymph
node abnormal.
- So, any change in lesion you must be conscious wit it to know if malignancy occurred and as a dentist, all your function is early
diagnosis to prevent that change.
- Erosion with red lesion in lateral surface of tongue or floor of the mouth, you must suspect it by malignancy.
- Or there is ulceration not respond to treatment and persists f or long time and in the same time there is no local factor.
- If there is keratinization in non-keratinized mucosa, it’s very dangerous change.
- If the ulcer has around it hallow of erythematous area, it means inflammatory reaction happen/ but when there is no
erythematous hallow around ulcer, it means there is defect on immunity.

 Characters of lesions that rise subsection of malignancy:

1. Erythroplakia: lesion is totally res or has a speckled red appearance.
2. Ulceration: lesion is ulcerated or present as an ulcer.
3. Duration: persist for more than two weeks.
4. Growth rate: rapid growth
5. Bleeding: bleeds on gentle manipulation
6. Induration: lesion and surrounding tissue is firm to the touch.
7. Fixation: attached to adjacent structures.

- Enough size to be handled (examined) by histologist (Dentist) because if small biopsy and in fixation
it will have shrinkage so difficult for handling, orientation and identification.

 Medical conditions that warrant special care:

1. Congenital heart failure
2. Hypertension
3. Coagulopathy
4. Poorly controlled DM
5. Immunosuppressive patient.

- In this cases management is done with the cooperation of other specialty

- Management: done by the dentist and another specialist
 Ex.: burning sensation of mouth, which may be due to iron deficiency anemia.

 Contraindication of biopsy:
1. Pigmented lesion: don’t cut in melanoma to avoid transformation to malignancy or
implantation of the lesion from one site to another site to avoid metastasis.
2. Pulsating lesion with vascular nature, if you make cutting, you will make profuse bleeding
that may not be controlled.
3. Local infection: acute, virulent Pyrogenic infection.
4. When the general health condition of the patient is very poor.

3|P a g e
 General principles of oral biopsy:
▪ Before the procedure is undertaken, the characteristics of the lesion (size, shape, consistency,
colour, texture, time of evaluation, associated signs& symptoms and regional node) should be
described in patient clinical records with presumed diagnosis and possible differential
diagnosis.
▪ Patient should receive information on the reasons why it is performed & complications that
may occur, avoiding terms that may cause anxiety.
▪ Informed consent is required

 How to take a biopsy: Notes: (Imp.)

▪ Scalpel. - Scalpel is the best surgical instrument for obtaining oral
▪ CO₂ laser. biopsy (MCQ).
▪ Electrosurgery. - The use of CO₂ laser is compromised by thermal cytological
▪ Aspiration. artifacts. The same is also applied to electrosurgical units.
▪ Radiosurgery.

 The biopsy should be large enough to include normal and suspicious tissue and for the
pathologist to give a diagnosis without further specimens.
Small samples are difficult to handle and certain processes as sample fixation may end in
reduction of the size of the specimen.

 Rules (principles, precautions): [Q] (V. Imp.)

1. Biopsy data:
▪ Name, age, sex, area of biopsy, lesion description, clinical data signs and symptoms and
expected diagnosis.
2. Avoid iodine containing antiseptics as they may cause permanent staining to some tissues. ‫(بيمتص‬
) ‫ى يف العينة ويدى صبغة تحت المكرسكوب‬
3. Avoid direct injection of LA into tissues LA is injected 1:2 cm around the lesion, as if directly into
the lesion it may change its nature.
4. Avoid electro surgery (to avoid burning of the tissues due to heat production) but in malignant
lesions it may be used if the growth is deep and can’t be removed.
 You should use traditional with scalpel better than Electrosurgery or laser to avoid thermal
conduction that may change nature of tissue taken to biopsy.
5. Avoid cutting from diseased to normal (But from health to disease) to prevent implantation of
malignant cells into normal cells & there may no normal tissue in specimen for comparing with
the diseased tissue. Also, more than one scalpel can be used.
6. Avoid areas of necrosis (not representative) (false
result).
7. Avoid cutting into highly vascular areas or angiomas.
8. Avoid cutting into well encapsulated lesions as S.G but
we make aspiration.
9. Avoid piercing the periosteum in carcinoma near the
bone to avoid lesion spreading.

4|P a g e
 10. Avoid crushing the lesion with a tweezers but handle gently.
11. Sufficient tissue should be removed.
12. Include normal tissues for comparison.
13. Small lesions should be removed completely (incisional biopsy)
14. Incisions should be deepened to the base of the lesion (superficial specimen may be not
identified so include all the layers of the lesion)
15. Suspended (traction) sutures should be used to immobilize the tissues and avoid biopsy swelling.
16. More than one specimen may be taken to represent the lesion.
▪ If spreading lesion to confirm the diagnosis.
17. Patient should know what is going on and agree (consent).
18. Use a large mouthed bottle to avoid sample squeezing in 10 % formalin because when you take
the biopsy back from the bottle you may crush it by tweezer.

Notes:
- For red and white lesions include both.
- For vesiculobullous lesions => fluid is more representative & intact vesicle or bulla should
be biopsied.
- Formalin must be 4 or 5 times as size of biopsy:
▪ For large lesion (24 hours)
▪ For small lesion (3-4 hours) and fixation is done immediately to avoid autolysis.

 Types of biopsy:
1- Excisional:
▪ For small lesions.
▪ Lesion is removed completely with safe margins as in fibro epithelial polyp-granulomas.

2- Incisional:
▪ For large lesions.
▪ Representative section of the lesions with a part of the adjacent tissues.
▪ May be taken from many sites.
▪ Avoid areas of necrosis

3- Aspiration:
▪ For fluctuant lesions, lymph nodes, SG, intact bulla and cystic lesions.
▪ As in vascular area (cyst) or in areas I should avoid cutting in it as in parotid gland.
▪ Large gauge needle is recommended

4- Punch:
▪ For inaccessible areas as throat using punch forceps.

5- Drill:
▪ For bone lesions.
▪ Fibro osseous lesions.
▪ A hollowed steel drill as large burs with cutting teeth at edges, mounted on a straight
handpiece.

5|P a g e
 6- Exfoliative cytology:
▪ It is the study of the superficial cells desquamated Cytology: you see individual cells
from various surfaces of the body as they reflect Biopsy: you see layer of tissue
many features of the underlying tissues.
▪ Done by papa Nicolau stain
▪ Important and excellent [but not exist in our faculty].
 Biopsy data sheet:
▪ Should be completed and specimen immediately labeled
▪ All previous history and description of the lesion must be recorded
▪ A random specimen: so not to give the researcher more information that may direct him to an
identification based on this information, so to reach the actual diagnosis of the lesion without
giving name or sex of the patient (only you give the specimen a number).

 Incisional biopsy:
▪ Only the portion of lesion is removed, select area most likely to demonstrate most advanced
disease.
▪ We take part from diseased area and another part from
healthy area on the form of elliptical incision and depth reach
the degree by which I can know superficial area and deep area
and we mostly preferred narrow and deep incision to shallow
(superficial) and wide incision because superficial won’t
include all the deep area.
▪ If incision is wide closure healing will be minimal.
▪ Beveling your incision to a narrow “V” base facilitates wound
closure.
▪ Fixative is standard over world 10 % formalin. (MCQ)
▪ If I suspect lesion as malignant lesion and results appear as
benign, I should ask to repeat the biopsy again as this may not
match the tissue, for you as dentist and for patient. Cut from the normal to
▪ I should take the biopsy to specialist no just technician. the diseased tissue
▪ If patient is confirmed to have malignant or lesion, I should
refer him to get him to the right track to get treatment early.

 Excisional Biopsy:
An excisional biopsy implies to the complete removal of the lesion for microscopic study.
Technique: The entire lesion with 2 to 3mm of normal appearing tissue surrounding the lesion is
excised if benign.
Elliptical incision: is carried out allowing for a narrow rim of normal peripheral tissue.

6|P a g e
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
▪ If The results show malignancy ➔ repeat the biopsy

 Exfoliative cytology:
▪ Exfoliative cytology is: examination of cells scraped from the surface of a lesion by tongue
depressor, spatula, and brush or occasionally of material in aspirates of a cyst.

Advantages: [Q] Disadvantages

1. Time saving cytology is quick procedure so
it saves lot of time. It is simple procedure. 1. Negative cytology does not exclude
Painless-as cancer as cancer cells may be deeper

2. It is painless, it causes minimum

2. Positive cytology may be misleading.
discomfort to the patient.
3. Low cost-cost of performing cytology is
less as compared to cost of biopsy.
4. No anesthesia it does not require
anesthesia.
5. False negative biopsy-it helps to check
against false negative biopsy
6. Follow up it is especially helpful in a follow
up detection of recurrent carcinoma.
7. Screening test-it is valuable for screening
lesions
8. Safety it is a safe procedure as
complications are rare
9. Rapid diagnosis- enables a rapid diagnosis 3. Positive results should be followed by
10. Bloodless procedure-as it is bloodless biopsy.
procedure there is less risk of delayed
wound healing and infection
11. Accuracy there are report of 100%
accuracy in lymph node aspiration from
metastatic carcinoma, melanoma.
Hodgkin's and Non-Hodgkin's lymphoma.
12. Special techniques such as
immunostaining can be applied. (very
easy)
13. Most useful for detecting virally-damaged
cells, acantholytic cells of pemphigus or
candidal hyphae.

7|P a g e
 Indication (Q):
1. Patient refuse biopsy
2. Debilitated patient
3. Special technique such as immunostaining can be applied.
4. Most useful for detecting viral damaged cells, acantholytic cells of pemphigus or candida
hyphae.
5. Periodic review - The father of cytology George Nicholas Papanicolaou
6. Rapid evaluation.

 Technique:
▪ By scraping the area by a moistened wooden tongue blade or metal spatula.
▪ Or by brush (preferably) as others only take superficial but brush take deeper.
▪ Smear should be rapidly spread over a glass slide which is homogenously to avoid crowding of
cells immediately immersed in absolute fixative of (95-100%) alcohol.
▪ After fixation, we sent to the cytopathologist for staining by Papanicolaou series of stains.

 Pap smear (Brush biopsy):

▪ Used in gynecology & can be used for oral mucosa
▪ This technique uses a round stiff bristle brush (cytobrush) to collect cells from the surface and
subsurface layers of a lesion by vigorous abrasion.
▪ Better as it includes 3 layers (superficial, intermediate, basal cells) while tongue depressor and
spatula only take the superficial layer.
▪ In malignant areas, exfoliation occurs more than benign because in benign between cells are
broken so hyper mitosis is faster than benign (for malignancy or dysplasia, exfoliation is easier
due to loss of cellular adhesion.
Why brush is better than spatula? (Imp)
 Because brush collect cells from
surface, intermediate & basal cells
but spatula collect cells only from the
surface.

8|P a g e
 Microscopic examination by cytology By biopsy
if it's class III , IV or V (biopsy must be taken)
- Dysplasia appears as cell changes classes: - Dysplasia appears as stages:
Class I: normal cells. Stage I: ⅓ is dysplastic
Class II: few dysplastic cells (some atypical cells as a Stage II: ⅔ is dysplastic
result of inflammation without evidences of Stage III: dysplastic from top to bottom
malignancy.)
Class III: altered N/C (intermediate nuclear changes, the
nuclei are abnormally large.)
Acantholysis: loss of intercellular
Class IV: shape and size of cells are changed (suggestion
connections in keratinocytes so cells float
of malignancy, nuclei are almost fill the cells and cells of in solution & cellular changes can be seen
different size and shape (pleomorphism). easily
Class V: all the site is dysplastic - It occurs in diseases such as pemphigus
- From III to V you should take a biopsy to confirm the vulgaris .
result and this is also with the biopsy.

Class I smear (Normal) Exfoliative Cytology Class II smear

- The nuclei are small compared to the cytoplasm
(normal nuclear/cytoplasmic ratios).
- The blue/green staining indicates that those cells
were acquired from deeper layers (diagnostic).
- The red/orange cells were acquired from
superficial layers (not diagnostic).
- Some change. - Slight atypia that is assumed to be the
result of inflammation.
- In this smear the nuclei are of normal size and shape.
There are, however, scattered inflammatory cells and
some subtle atypical changes in the upper left cell. As
with the last image, most of the cells were derived from
deeper cells (blue/green).

Exfoliative Cytology Class III Smear

- Follicular change intermediate. Exfoliative Cytology Class IV Smear Exfoliative Cytology Class IV
- The nuclei of these cells are - Suggestive to be malignancy. - Smear
abnormally large (altered Nuclei almost fill the cells (altered - There is altered N/C ratio,
nuclear/cytoplasmic ratio) indicating N/C ratio). - Keratinized superficial pleomorphism, and
that they may (not certain) be cells will take red color when stained enlarged/multiple nuclei.
malignant. and deep non-keratinized cells will - The lesion is malignant.
- That these changes occur in superficial take blue color. - Cells are of - The definition of Class V =
cells (red/orange) is worrisome. different sizes and shapes "Most cells are atypical;
However, there are a number of (pleomorphism). In other words, definitely malignant."
scattered
9 | P a inf.
g e cells. there is evidence of anaplasia and,
therefore, malignancy.
 Vital stains:
 Toluidine blue stain: (1%)
▪ Very good and its technique depend on that malignant cells take stain more than benign
because it’s acidophilic and chromogenic (has affinity to stick to area with acid) and DNA has
high acid percent so when mitosis occur, acid increase so affinity of stain to stick to
malignancy is than benign.
▪ Technique: Patient wash his mouth and we put toluidine blue. (Oral Q)
▪ Also, we used acetic acid, if benign color disappear and If malignant color become
prominent.
▪ The biopsy is taken from the darkest color area (most representative area).
‫ وامسح الليجن بيها‬1% toluidine blue ‫اخل البيشنت يتمضمض و اجيب البتاعه ال يل بننضف بيها الودان دي وابلها بال‬
‫= ي‬
‫ى‬
.. ‫ال هو الخل وامسح برضه بيه يف نفس المكان‬ ‫ى‬
‫ى‬ ‫ ي‬acetic acid ‫تان وبعدين اجيب‬
‫يتمضمض ي‬ ‫ى‬
‫اخل البيشنت‬
‫واسيبها شوية وبعدين ي‬
..
‫ هتفضل الصبغة وهتبق غامقة ف‬malignant cells ‫ فيه‬tissue ‫ الضبغة هتوح لكن لو ال‬normal ‫ ده‬tissue ‫لو ال‬
‫ من ى‬biopsy ‫هاخد ال‬
. )most representative area ( ‫اكت مكان غامق‬

 Fine needle aspiration biopsy:

▪ Aspiration of cells or fluid for subsequent analysis Technique consists of repeatedly passing
a needle under negative pressure through a lesion to collect cells.
▪ The technique is usually indicated for lesions of major salivary glands and neck masses Fluid
aspirated from a lesion can also be sampled Generally requires analysis by a
cytopathologist.

 Used to rule out &/or differentiate

- Fluid filled cavities
- Vascular lesions
- Hematomas
- Empty cavities
- Cyst (when lesion is cystic fluid is yellow in color occasionally red due to presence of blood)

 Lymph nodes-FNAB is an excellent initial diagnostic modality in the evaluation of lymphadenopathy. Many infectious
processes can be diagnosed because cultures may be obtained from bacteria and fungus.
 Aspirates from enlarged lymph nodes can differentiate between- (Reactive hyperplasia or inflammation. - Malignant disease.
- Lymphoma.)
 It is also used to confirm the cervical lymph node metastasis from previously treated local neoplasms

 Drill biopsy
 This type of biopsy is used mainly for
intra-osseous lesions A drill in a dental
engine is used to remove a core from the
Centre of the tumor.

10 | P a g e
 Frozen sections: (intraoperative)
▪ This is quick method of diagnosis that can be used during surgery to make sure that the margin
of the lesion is clear
▪ Can establish, at operation, whether or not a tumor is malignant and whether excision needs
to be extended.
▪ Can confirm, at operation, that excision margins are free of tumor.
▪ Appearances differ from those in fixed material.
▪ Freezing artefacts due to poor technique can distort the cellular picture.
▪ Definitive diagnosis sometimes impossible.

N. B - If the surgeon is on an operation and took a specimen and want to be sure that he took
safety margin, the biopsy is taken frozen to the lab during the operation and a report shortly (5
min) come confirming if you’re in safety margins or not to extent the margins to remove all the
malignant lesion.
‫وال أل ف بياخد ال‬safety margin ‫الجراح بياخدها اثناء ما بيعمل العملية –بيشيل ورم مثال – وعاوز يعرف هو وصل لل‬
‫ويبعتها عل المعمل علطول وبتجيله النتيجة ى يف خالل خمس دقايق اثناء ما بيعمل العملية عشان ي أكد‬frozen biopsy
. ‫ده وال هيشيل كمان‬margin ‫عليه هيقف عند ال‬

 Indication:
1. To make immediate surgical therapeutic decision
2. To determine whether a lesion is benign, malignant or non-neoplastic.
3. Establish accuracy of clearance of margin after resection.
4. It reduces the time of processing from 18 hours to 5 minutes.

 Methods:
▪ Freezing microtome using CO2 gas ▪ Refrigerated microtome(cryostat)

 Instrument used:
▪ Blade. ▪ Forceps. ▪ Needle.
▪ Suture. ▪ Anesthesia. ▪ Haemostatic agent.

 Possible reasons for failures in histological diagnosis:

1- Specimen poorly fixed or damaged during removal.
2- Specimen is unrepresentative of the lesion or too small.
3- Plane of histological section does not include critical features.
4- The condition does not have diagnostic histological features, e.g. aphthous ulcers.
5- The histological features are difficult to interpret; e.g. malignant tumors may be so poorly differentiated that their type
cannot be determined.
6- Inflammation may mask the correct diagnosis

 Please Remember
- Discovering a lesion is the first step to making a diagnosis If you find yourself 10 years into practice
and you have not diagnosed any dysplasia, you are missing lesions guaranteed!
-Not all tumors are cancers, and not all cancers are tumors Diagnosing cancer is Very important
specially in early stage.

Sources:
▪ Lecture. ▪ Dr 's data.
▪ Handout.
11 | P a g e