biopsy 000

8/20/2019 Biopsy 000

1/45

Principles and Techniques ofPrinciples and Techniques of

BiopsyBiopsy

8/20/2019 Biopsy 000

2/45

Principles and Techniques ofPrinciples and Techniques of

BiopsyBiopsyIt is important to develop a systematic

approach in evaluating a patient with a

lesion in the Oral and Maxillofacialregion.

8/20/2019 Biopsy 000

3/45

These steps include :These steps include :

detailed health history

history of the specific lesion

clinical examination

radiographic examination

!a"oratory investigations#urgical specimens for histopathologic

evaluation

8/20/2019 Biopsy 000

4/45

$ealth $istory$ealth $istory

n accurate health history may disclose predisposing

factors in the disease process or factors that affect the

patients management.

%p to &'( of systemic deseases can "e discovered

through history ta)ing.

The same can "e true of oral lesions when one is

familiar with the natural progression of the more

common disease processes.

8/20/2019 Biopsy 000

5/45

Medical conditions thatMedical conditions that

warrant special care include:warrant special care include:*ongenital heart defects

*oagulopathies

$ypertension

Poorly controlled dia"etics

Immunocompromised patients

8/20/2019 Biopsy 000

6/45

$istory of the !esion$istory of the !esion

8/20/2019 Biopsy 000

7/45

+uestions to s) +uestions to s)

,uration of the lesion

*hanges in si-e and rate of change

*hanges in the character of the lesion.

– !ump to ulcer etc

ssociated systemic symptoms:

– fever

– nausea

– anorexia

8/20/2019 Biopsy 000

8/45

More +uestions to s) More +uestions to s)

Pain

"normal sensations

nesthesia feeling of swelling

Bad taste or smell

,ysphagia#welling or tenderness of ad/acent lymph

nodes

*haracter of the pain if present

8/20/2019 Biopsy 000

9/45

$istorical 0easons for the$istorical 0easons for the

!esions:!esions:Trauma to the area

0ecent toothache

$a"its

8/20/2019 Biopsy 000

10/45

*linical 1xamination*linical 1xamination

The clinical examination should always

include when possi"le:

– Inspection

– Palpation

– Percussion

– uscultation

8/20/2019 Biopsy 000

11/45

*linical 1valuation*linical 1valuation

The anatomic location of the lesion2mass

The physical character of the lesion2mass

The si-e and shape of the lesion2mass #ingle vs. multiple lesions

The surface of the lesion

The color of the lesion

The sharpness of the "oundaries of the lesion

The consistency of the lesion to palpation

Presence of pulsation

!ymph node examination

8/20/2019 Biopsy 000

12/45

0adiographic 1xamination0adiographic 1xamination

The radiographic appearance may provide clues

that will help determine the nature of the lesion.

radiolucency with sharp "orders will often "ea cyst

ragged radiolucency will often "e a more

aggressive lesion

0adiopaque dyes and instruments can help

differentiate normal anatomy

8/20/2019 Biopsy 000

13/45

!a"oratory Investigation!a"oratory Investigation

Oral lesions may "e manifestations of

systemic disease.

If a systemic disease is suspected it

should "e pursued.

8/20/2019 Biopsy 000

14/45

These include:These include:

Tumor of hyperparathyroidism

Padgets disease

Multiple myeloma

,etermination of serum calcium

phosphorus and al)aline phosphatase and

protein can "e very useful in excluding

certain pathological processes.

8/20/2019 Biopsy 000

15/45

Indications for BiopsyIndications for Biopsy

ny lesion that persists for more than 3 wee)s

with no apparent etiologic "asis

ny inflammatory lesion that does not respondto local treatment after 4' to 45 days.

Persistent hyper)eratotic changes in surface

tissues.

ny persistent tumescence either visi"le or

palpa"le "eneath relatively normal tissue.

8/20/2019 Biopsy 000

16/45

Indications for BiopsyIndications for Biopsy

Inflammatory changes of un)nown cause that

persist for long periods

!esion that interfere with local functionBone lesions not specifically identified "y

clinical and radiographic findings

ny lesion that has the characteristics ofmalignancy

8/20/2019 Biopsy 000

17/45

*haracteristics of lesions that raise the*haracteristics of lesions that raise the

suspicion of malignancy.suspicion of malignancy. 1rythroplasia6 lesion is totally red or has a speckled red

appearance.

%lceration6 lesion is ulcerated or presents as an ulcer.

,uration6 lesion has persisted for more than two weeks.

7rowth rate- lesion exhibits rapid growth

Bleeding6 lesion bleeds on gentle manipulation

Induration6 lesion and surrounding tissue is firm to thetouch

8ixation6 lesion feels attached to adjacent structures

8/20/2019 Biopsy 000

18/45

9hat is a Biopsy9hat is a Biopsy

Biopsy is the removal of tissue for the

purpose of diagnostic examination.

8/20/2019 Biopsy 000

19/45

Types of BiopsyTypes of Biopsy

Oral cytology

spiration "iopsy

Incisional "iopsy

1xcisional "iopsy

;eedle "iopsy

8/20/2019 Biopsy 000

20/45

Oral *ytologyOral *ytology

,eveloped as a diagnostic screening

procedure to monitor large tissue areas for

dysplastic changes.Most frequently used to screen for uterine

cervix malignancy

May "e helpful with monitoringpostradiation changes herpes pemphigus.

8/20/2019 Biopsy 000

21/45

The ,isadvantage of oral cytologicalThe ,isadvantage of oral cytological

procedures include:procedures include:;ot very relia"le with many false positives.

1xpertise in oral cytology is not widely

availa"leThe lesion is repeatedly scraped with a

moistened tongue depressor or spatula type

instrument. The cells o"tained are smeared on

a glass slide and immediately fixed with a

fixative spray or solution.

8/20/2019 Biopsy 000

22/45

spiration Biopsyspiration Biopsy

spiration "iopsy 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

– 9hen exploration of an intraosseous lesion is

indicated

8/20/2019 Biopsy 000

23/45

spirationspiration

n 4< gauge needle on a = or 4' ml

syringe is inserted into the area under

investigation after anesthesia is o"tained.The syringe is aspirated and the needle

redirected if necessary to find the fluid

cavity.

8/20/2019 Biopsy 000

24/45

Incisional BiopsyIncisional Biopsy

n incisional "iopsy is a "iopsy 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 "e sampled

8/20/2019 Biopsy 000

25/45

Incisional BiopsyIncisional Biopsy

Indications:

– #i-e limitations

– $a-ardous location of the lesion

– 7reat suspicion of malignancy

Technique:

– 0epresentative areas are "iopsied in a wedge fashion.

– Margins should extend into normal tissue on the deep

surface.

– ;ecrotic tissue should "e avoided.

– narrow deep specimen is "etter than a "road shallow

one.

8/20/2019 Biopsy 000

26/45

1xcisional Biopsy1xcisional Biopsy

n excisional "iposy implies the complete removal of

the lesion.

Indications: – #hould "e employed with small lesions. !ess than 4cm

– The lesion on clinical exam appears "enign.

– 9hen complete excision with a margin of normal tissue is

possi"le without mutilation.

8/20/2019 Biopsy 000

27/45

1xcisional Biopsy1xcisional Biopsy

Technique:

– The entire lesion with 3 to >mm of normal

appearing tissue surrounding the lesion is excisedif "enign.

8/20/2019 Biopsy 000

28/45

Principles of #urgeryPrinciples of #urgery

8/20/2019 Biopsy 000

29/45

nesthesianesthesia

Bloc) anesthesia is preferred to

infiltration

9hen "loc)s are not possi"le distant

infiltration may "e used

;ever in/ect directly into the lesion

8/20/2019 Biopsy 000

30/45

Tissue #ta"ili-ationTissue #ta"ili-ation

,igital sta"ili-ation

#peciali-ed retractors2forceps

0etraction sutures

Towel *lips

8/20/2019 Biopsy 000

31/45

$emostasis$emostasis

#uction devices should "e avoided

7au-e compresses are usually adequate

7au-e wrapped low volume suction may

"e used if needed

8/20/2019 Biopsy 000

32/45

IncisionsIncisions

Incisions should "e made with a scalpel.

They should "e converging

#hould extend "eyond the suspected depth of the lesion

They should parallel important structures

Margins should include 3 to >mm of normal appearing

tissue if the lesion is thought to "e "enign.

=mm or more may "e necessary with lesions that appearmalignant vascular pigmented or have diffuse "orders.

8/20/2019 Biopsy 000

33/45

$andling of the Tissue$andling of the Tissue

#pecimen#pecimen,irect handling of the lesion will expose

it to crush in/ury resulting in alteration

the cellular architecture.

8/20/2019 Biopsy 000

34/45

#pecimen *are#pecimen *are

The specimen should "e immediately

placed in 4'( formalin solution and "e

completely immersed.

8/20/2019 Biopsy 000

35/45

Margins of the BiopsyMargins of the Biopsy

Margins of the tissue should "e identified

to orient the pathologist. sil) suture is

often adequate. Illustrations are alsovery helpful and should "e included.

8/20/2019 Biopsy 000

36/45

#urgical *losure#urgical *losure

Primary closure of the wound is usually

possi"le

Mucosal undermining may "e necessary

1lliptical incision on the hard palate or

attached gingiva may "e left to heal "y

secondary intention.

8/20/2019 Biopsy 000

37/45

Biopsy ,ata #heetBiopsy ,ata #heet

"iopsy data sheet should "e completed

and the specimen immediately la"eled.

ll pertinent history and descriptions ofthe lesion must "e conveyed.

8/20/2019 Biopsy 000

38/45

Intraosseous and $ard TissueIntraosseous and $ard Tissue

BiopsyBiopsyIntraosseous lesions are most often the

result of pro"lems associated with the

dentition.

8/20/2019 Biopsy 000

39/45

Indications for IntraosseousIndications for Intraosseous

BiopsyBiopsyny intraosseous lesion that fails to

respond to routine treatment of the

dentition.ny intraosseous lesion that appears

unrelated to the dentition.

8/20/2019 Biopsy 000

40/45

Palpation of the area of the lesion with comparison

to the opposite side.

ny radiolucent lesion should have an aspiration

"iopsy performed prior to surgical exploration.

– Information from the aspiration will provide valua"le

information a"out the lesion.

• #olid

• 8luid 8illed

• ?ascular

• 9ithout *ontents

*linical 1xam*linical 1xam

8/20/2019 Biopsy 000

41/45


Mucperiosteal flaps should "e designed to allow

adequate access for incisional2excisional "iopsy.

Incisions should "e over sound "one*ortical perforation must "e considered when

designing flaps

8laps should "e full thic)ness

Ma/or neurovascular structures should "e avoided

8/20/2019 Biopsy 000

42/45


Osseous windows should "e su"mitted with the

specimen

Osseous preformations can "e enlarged to gainaccess

void roots and neurovascular structures

The tissue consistency and nature of the lesion will

determine the ease of removal

8/20/2019 Biopsy 000

43/45


Incisional "iopsies only require removal of a

section of tissue

#oft tissue overlying the lesion should "ereapproximated following thorough irrigation

of the operative site.

The specimen should "e handled as previously

descri"ed

8/20/2019 Biopsy 000

44/45

Biopsy 0esults: 9hat If Biopsy 0esults: 9hat If

They don@t corro"orate your clinical impression

– 0epeat the "iopsyAAA

– ,etermine if the tissue was loo)ed at "y an OralPathologist

– The results show malignancy

8/20/2019 Biopsy 000

45/45

9hen To 0efer 8or Biopsy9hen To 0efer 8or Biopsy

9hen the health of the patient requires special management

that the dentist feel unprepared to handle

The si-e and surgical difficulty is "eyond the level of s)ill

that the dentist feels he2she possesses

If the dentist is concerned a"out the possi"ility of

malignancy

biopsy 000

Documents