principle of oral biopsy Abdusalam Alrmali Tripoli University Libya

1. Principles of oral biopsy
By
Dr. Abdusalam Alrmali
The key to reduction of death due to oral cancer is early detection,
and dentist can play an important role 
How ?
 Thorough history , oral examinations, and detection of the early
lesions
 Biopsy and histological evaluation of the lesion
From the history will know the following Risk Factors:
 Tobacco use
 Alcohol use
 Exposure to sunlight
 Age
 Gender
 Race
Physical Exam:
 Be systematic and thorough so as not to miss things
 For the same reason, go to the area of interest last
 Inspection and palpation

2.  Location: Be descriptive, diagrams can be very helpful
 Try and ascertain what tissues are involved, eg epithelial or
submucosal
 Certain locations correspond to certain diseases – e.g. oral cancer
and lateral border of the tongue vs. the dorsum of the tongue
 Size and shape of the lesion
 Accurate measurements allow to follow the changes in the
size of the lesion
 Measurement of the lesion is used in the T staging of oral
squamous cell carcinoma and salivary gland malignancies
 Surface of the lesion
 Verruciform
 Smooth
 Ulcerated
 Associated with hematoma
 Filled with with granulation tissue or necrotic debris
 Expresses purulence
 Relation of the lesion to the surrounding tissues
 fixed vs. freely mobile
 A fixed lesion is often a finding indicating infiltration of
adjacent tissues

3.  Consistency of the lesion
– Soft = lipoma
– Firm = fibroma
– Hard = torus
– Indurated = firm-hard
Consistency of a lesion will give you a clue as to its component tissues
 Fluctuation
Fluctuation is a term describing a wave like motion felt on palpation of
a lesion
Describes a fluid component
 Pulsations
o Thrills = palpable murmur
o Bruit = audible murmur
o These are descriptors of vascular lesions and malformations. Their
presence should prompt referral to a specialist for management.
Lymph node examination
o Must be performed as part of any examination.
o Lymph nodes should always be examined before any surgery so as
to not confuse reactive adenopathy with their pathologic
involvement

4.  Lymph Node Exam must include these descriptors:
1. Size - less than 1 cm usually not pathologic
2. Tenderness - painful vs. painless
3. Degree of fixation
4. Texture - soft, firm, fluctuant, hard
Radiographs - PA’s, Panoramic radiographs, computed tomography,
magnetic resonance imaging, bone scanning, chest X rays, …
1. Benign versus aggressive features
5. Laboratory Investigations
1. Based on your findings and differential diagnosis
Features that arise the suspicion of malignancy:
Warning Signs:
 Leukoplakia
 Erythroplakia
 Lump or thickening of oral soft tissue

5.  Soreness or “lump” in throat
 Difficulty chewing or swallowing
 Ear pain
 Difficulty moving jaw or tongue
 Hoarseness
 Numbness of tongue or mouth
 Swelling of the jaw
Clinical features of squamous cell carcinoma:
 Leukoplakia
 Erythroplakia
 Non-healing ulcer
 Exophytic
 Verrucous
 Indurated

6. Oral biopsy
Is the removal of tissue from a living individual for diagnostic
examination.
 The aim of biopsy is to :
• Define a lesion on the basis of its histopathological aspect;
• To establish a prognosis in malignant and premalignant lesions;
• Facilitate the prescription of specific treatment;
• Contribute to the assessment of the efficacy of the treatment;
• Act as a document with medical-legal value.
Indications for biopsy :
1. A lesion that persists for more than 2 weeks with no apparent
etiologic basis.
2. An inflammatory lesion that doesn't respond to local treatment after
14 days (i.e, after removing local irritant ).
3. Lesions that interfere with local function e.g fibroma
4. Persistent hyperkeratotic changes in surface tissues.
5. A persistent lesion, either visible or palpable beneath a relatively
normal tissue.
6. A persistent traumatic ulcer doesn't resolve after removing the
cause .
7. Bone lesions not specifically identified by clinical and radiographic
findings.
8. Any lesion that has the characteristic of malignancy
Contraindications of biopsy:
1. In case of acute infection near the site of biopsy
2. Uncontrolled compromised patient e.g bleeding disorder,
anticoagulant .
3. When its sure from malignancy
4. Incisional biopsy absolute contraindication in vascular and
pigmented lesions.

7. 5. Incisional biopsy is also contraindicated in major salivary gland
lesions.
When is oral biopsy not needed?
 There is no need to biopsy normal structures;
 There is no need to biopsy irritative or traumatic lesions that
respond to the removal of a presumed local irritant;
 There is no need to biopsy inflammatory or infections lesions that
respond to specific local treatments, as pericoronitis, gingivitis or
periodontal abscesses;
Types of oral biopsy :
According to the procedures applied, oral biopsy can be classified into:
 Oral cytology
 Aspiration biopsy
 Fine needle aspiration cytology
 Incisional biopsy
 Excisional biopsy
 Punch biopsy
 Drill biopsy
 Frozen section biopsy
Timing of the biopsy:
• Pre-operative
• Intra-operative
• Post-operative when aimed at checking the efficiency of a
treatment
Pre-biopsy Screening test:
Toluidine Blue test :
• A vital stain technique
• Displays affinity for areas of dysplasia, malignancy and high cell
turn over

8. Toluidine Blue- Instructions for use:
 Swish for 1 minute then spit, each in order:
1. 0.25% Acetic acid
2. Water
3. Toluidine blue
4. 0.25% Acetic acid
5. Water
Oral Brush Biopsy
 The brush is sterile
 One Oral brush test kit per oral lesion
 The brush was designed to penetrate to the basement membrane
and thus achieve a complete trans-epithelial specimen
 Unlike cytology instruments which collect only superficial cells,
the brush biopsy obtains cells from all three epithelial layers of the
oral mucosa: superficial, intermediate and basal
Indications:
 For herpetic infection
 Candidal infection
 Dysplastic changes

9.  Think of this technique as a screening tool
 This kit helps you decide which lesions need to undergo
conventional biopsy
 If a lesion is highly suspicious, skip this option and go right to the
incisional/ excisional biopsy
Exfoliative cytology
 Oral exfoliative cytology should not be used as a substitute
for a conventional biopsy because of the false-negative
results
 The technique consists of scrapping the lesion with a tongue
blade or spatula and spreading the scrapping over a glass
slide, which is fixed immediately in 95% ethyl alcohol, then
allow to dry in air and examined

10. Aspiration biopsy
This is the use of needle and syringe to penetrate a lesion for aspiration
of it's contents.
Indications :
1. To determine the presence of fluid within a lesion.
2. To a certain the type of fluid within a intraosseous lesion as cyst
3. To rule out a vascular lesion that can cause life threatening
hemorrhage.
Technique :
1. An 18- gauge neelde is connected to a 5 or 10 ml syringe
2. The area is anesthesized and the needle is inserated into the depth
of the mass during aspiration
3. For bony lesion either forcing the needle to perforate the cortex or
opening of small flap to facilitate the aspiration.
Fine Needle Aspiration cytology
 Technique consists of repeatedly passing a needle, under negative
pressure, through a lesion to collect cells
 Generally requires analysis by a cytopathologist
Indications:
 Major Salivary gland swelling
 Neck masses

11.  Lymph node masses
Incisional biopsy
 Technique simple, only a portion of the lesion is removed
 Selects a representive portion of the lesion, especially select areas
most likely to demonstrate most advanced disease
Indications:
 Large lesions with more than 1cm in diameter
 Hazardous location
 Malignancy suspected
Technique :
 Biopsy of a wedge of representative tissue
 Several regions may be sampled
 Avoid necrotic tissue
 Areas of tissue transition can be useful, such as the margin of the
lesion
 Wedge should be deep enough to sample the full depth of the
lesion and its transition to normal tissue
Excisional Biopsy
 Removes the entire lesion at the time of tissue sampling
 A margin of normal tissue is generally included

12.  Offers the advantage of definitive treatment at the time of
diagnosis
 Indications:
– Smaller lesions, < 1cm
– Pigmented and small vascular lesions
– Benign lesions
Principle: lesion and 2-3mm margin of normal tissue is excised

13. Drill biopsy
 This type of biopsy is used mainly for intra-osseous lesions
 A drill in a dental engine to remove a core from the centre of the
tumour is done
Frozen sections
 This is quick method of diagnosis that can be used during surgery
to make sure that the margin of the lesion is clear

14.  Frozen sections for tumour diagnosis usually provide a rapid and
highly reliable answer and the only problem may be that of
conveying the specimen from theatre to laboratory rapidly and
without deterioration
Armamentarium for biopsy
Set of instruments necessary for soft tissue specimen sampling by
biopsy.
Steps :
 Local anesthesia :infiltration or field block.
– Careful not to distort your margins 1 cm away
 Haemostasis
– Sponge > suction
 Incision
– Scalpel/punch > electrocautery
– 2-3mm of normal tissue
 Tissue Handling

15. – Gentle, do not crush your specimen
– Identification of margins
– Sutures for orientation
– Specimen care
– Gentle handling with forceps
– Closure
– Undermining as needed
– Pathology Sheet
– Be descriptive
 N.B: The use of CO2 laser is compromised by thermal cytological
artifacts. The same is also applied to electrosurgical units.
Errors to be avoided when taking oral biopsies:
 Taking insufficient amount of tissue in extension and depth
 Pressing the sample with tweezers, producing tissue tears
 Infiltrating anaesthetic solution within the lesion
 Using an insufficient volume of fixing solution
 Inclusion of undesired material in the sample; glove powder,
calculus, restorative materials, etc.

16. Stabilization of the lower lip before biopsy, using assistant's finger's.
Stabilization of tissue with mechanical device. C, Stabilizaticn of tissue
with traction sutures. Two silk sutures are used to stabilize tongue before
excisional biopsy. They are placed through substance of tongue (both
mucosa and muscle) to prevent pulling through tissue. H, Lesion is
removed after elliptic incision was made around it. i, Resorbable sutures
are placed to approximate muscle. J, Mucosa is closed.

17. Marking the biopsy with sutures
Sample of biopsy sheet:
 Patient details: name, gender, race, age, address,
 medical and social history
 Clinical details
 History: symptoms, previous biopsy and treatment
 Examination: signs, size, shape, position, texture, color
 Investigations: microbiology, hematology, radiology
 Biopsy type
 Previous biopsy number/s
 Orientation: use a diagram
 Clinical diagnosis

18. Biopsy data sheet :
Date ……………………. Case number…………………..
Patient name :……………….. gender…………….. age ………………..
Race …………………. Address……………………………………..
Home phone ……………………………work phone……………………..
Occupation…………………………
submitting doctor's name………………………… phone ………………
email…………………………………………………………….
History:
asymptomatic white plaque of unknown duration but first noticed by
patient about 2 months ago, left lateral border of tongue, patient denies (
tobacco usage, alcohol usage), the lesion is not painful , no local trauma
noticed, past medical history is unremarkable.
Type of biopsy: incisional
Clinical description /location: 3*5 cm white , rough surface plaque on
lateral surface of the tongue, non-ulcerated, with uniform thickness.
Clinical margin:
Anterior border tagged with single suture, superior border tagged with 2
sutures.
Provisional clinical diagnosis: leukoplakia, verrucous carcinoma, SCC.
Additional comments / radiographic attachment if present .

19. This table illustrate oral cavity structures and their drainage
LN
Area Draining lymph nodes
Cheek Submandibular
Upper lip Submandibular
Lower lip lateral part Submandibular
Lower lip middle part Submental
Mandibular gingiva Submandibular
Anterior Mandibular teeth Submental
Posterior mandibular teeth Submandibular
Maxillary teeth Deep cervical
Maxillary gingiva Deep cervical
Tongue tip Submental
Lateral border of tongue
anterior two third
Submandibular
Posterior one third Deep cervical
Floor of mouth Submandibular
Hard Palate Deep cervical
Soft palate Retropharyngeal & Deep
cervical
Tonsil & uvula Jugulodigastric