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The Oral Biopsy: Indications, Techniques

C O N T I N U I N G E D U C AT I O N
and Special Considerations T
D
Dr. Molly S. Rosebush, Dr. K. Mark Anderson, A
Dr. Swati Y. Rawal, Dr. Harry H. Mincer, Dr. Yeshwant B. Rawal
EXAM #19

Dr. Molly S. Rosebush Dr. K. Mark Anderson Dr. Swati Y. Rawal Dr. Harry H. Mincer Dr. Yeshwant B. Rawal

Introduction for diagnosis. When recognizing Biopsy Indications: Hard Tissue


Accurate diagnosis and treatment of tissue abnormalities, the clinician Lesions
oral disease is an essential component must first attempt to determine the Few bony abnormalities can be
of the patient’s comprehensive dental etiology. Evidence of traumatic injury accurately diagnosed based on their
care and the foundation of high-quality or signs and symptoms of infection radiographic features. Idiopathic
dentistry. Inaccurate diagnosis or (e.g. candidiasis, herpes simplex) may osteosclerosis, condensing osteitis
failure to diagnose oral disease may provide the clinician with sufficient and cemento-osseous dysplasia are
have profound implications for both information to arrive at a provisional conditions that are radiographically
the patient and the clinician. A wide diagnosis. In these cases, the clinician unique, and the expertise of the
array of procedures and techniques may choose to provide treatment and clinician in diagnosing these conditions
is available to assist in the diagnosis to monitor the lesion for a period of using radiographs is paramount.
of oral disease. Every patient should 1-2 weeks for resolution. Alternatively Most bony lesions cannot be
receive a thorough head and neck lesions determined to be self-healing diagnosed exclusively based on their
examination and appropriate dental and not requiring any treatment (except radiographic appearance. Confirmatory
radiographs. The clinical and palliative therapy) may be followed-up. diagnosis requires a biopsy and
radiographic examinations may provide After a 2-week period, any remaining microscopic examination. Periapical
sufficient information for the diagnosis abnormality or any lesion that inflammatory lesions and intrabony
of certain entities. However, many proves refractory to local therapy is cysts and tumors show radiographic
diseases of the mucosa, other soft tissue indicated for biopsy. changes that are indefinite beyond
and bone require additional information Leukoplakia, erythroplakia and a presumptive clinical diagnosis.
to make a precise diagnosis. This persistent or widespread ulcerations Given the differences in treatment
information in many instances may be necessitate biopsy. Persistent changes and prognosis for many of these
provided by biopsy and submission of in color or any new growth noted on entities, identification of these lesions
tissue for histopathologic examination. examination should also be considered mandates biopsy. Further treatment,
The purpose of this paper is to outline for biopsy. Many submucosal lesions if necessary, will then be dictated
the indications for oral biopsy and other have no diagnostic color or surface by the definitive histopathologic
allied techniques and the procedures changes, and these lesions are rarely diagnosis. We have reported twice in
that will help ensure accurate distinguishable by palpation alone. For this journal on periapical/periodontal
diagnosis. these, biopsy is indicated, especially if inflammatory lesions that upon biopsy
recent change in size or symptoms is and microscopic examination revealed
Biopsy Indications: Soft Tissue reported. No matter how confident a metastatic breast carcinoma in one
Lesions the clinician may be with their and Langerhans cell histiocytosis in the
For any unknown lesion or clinical diagnosis, any tissue removed second.1, 2
condition of the oral mucosa, a from a patient should be submitted Clinical and radiographic signs
scalpel biopsy is the gold standard for histopathologic examination. and symptoms of bony pathology can

90-2 • The Oral Biopsy: Indications, Techniques and Special Considerations 17


C O N T I N U I N G E D U C AT I O N

Figure 1 Figure 2 Figure 3

Labeled container of 10% neutral Labeled container of Michel’s solution for An excisional biopsy specimen indicating
buffered formalin for fixation and transporting tissue for orientation margins with long and short
transport of routine biopsy specimen. direct immunofluorescence. length sutures.

also alert the clinician to the necessity to remove lesions by scalpel, reserving should be reserved until after the
of biopsy. Rapid bone loss, irregular laser or other cautery instruments to biopsy as presurgical steroid use may
widening of the periodontal ligament, control bleeding after the specimen alter the histopathologic and direct
spiking root resorption and tooth has been obtained. Excessive tissue immunofluorescence findings altogether,
mobility in the absence of trauma or clamping with forceps may also distort rendering the biopsy procedure useless.
an identifiable source of inflammation or crush tissue specimens. Excisional biopsy involves complete
is often an ominous sign and should be A frequent question is whether removal of the lesional tissue. This is
evaluated carefully. Expansion, pain an incisional or excisional biopsy is most appropriate for small, accessible
and paresthesia are some other features indicated. Incisional biopsies sample lesions that are easily amenable to
of hard tissue lesions that would warrant only a portion of the lesion to establish surgery (e.g. mucocele, pyogenic
biopsy and histopathologic examination. a diagnosis prior to treatment. This granuloma and irritation fibroma).
is most appropriate for large lesions Excision of mucoceles must include the
Intraoral Biopsy Techniques where complete surgical removal is few lobules of minor mucous glands that
An adequate and appropriate tissue impractical. If the lesion is ulcerated, drain into the mucocele. This minimizes
sample is critical when obtaining a the clinician should strive to include a the recurrence potential of these lesions.
biopsy. The clinician should strive portion of the adjacent intact epithelium
to remove a reasonably large, intact in the specimen. For extensive Specimen Preparation, Placement,
specimen without causing significant lesions, sampling of multiple areas and Orientation:
patient morbidity. Specimens that are is recommended to ensure accurate When a biopsy specimen is taken
too small or of inadequate depth may assessment. A large leukoplakic or from the oral cavity, immediate
be insufficient for accurate microscopic erythroplakic patch may demonstrate immersion into a fixative is imperative.
interpretation and are often difficult moderate epithelial dysplasia in one Inadequate fixation results in tissue
to orient properly for sectioning and area and a frank, invasive squamous cell degeneration, causing difficulty in
mounting on a slide. Fragmented carcinoma in an adjoining area. interpretation. The fixative most
specimens create similar difficulties. A Incisional biopsy is also indicated commonly used for routine biopsies
mucosal biopsy should be of adequate for suspected autoimmune disorders is 10% neutral buffered formalin
depth to include the entire layer such as pemphigus vulgaris. These (Fig.1). For suspected autoimmune or
of epithelium and a portion of the tissue samples should be submitted for vesiculobullous disorders, two tissue
underlying connective tissue. routine histopathologic examination samples should be submitted: one
Of further importance is the as well as direct immunofluorescence in formalin for routine microscopy
instrumentation used in the acquisition studies. Care must be taken to sample and the other in Michel’s solution for
of the tissue sample. In order to perilesional tissue, with abundant direct immunofluorescence (Fig.2).
provide an optimal tissue sample with epithelium. If epithelium is lacking Immunofluorescence studies cannot
minimal distortion, a scalpel biopsy is or separated from the underlying be performed on tissue submitted in
preferable. Heat produced by lasers and connective tissue, interpretation formalin.
electrocautery often distorts the tissue, and diagnosis are impossible. In All biopsy containers must be
making diagnosis difficult. It is best this context, any steroid therapy appropriately labeled to identify the

18 Journal of the Tennessee Dental Association • 90-2


patient and the anatomic site if more Other Diagnostic Methods maintained and a fail-safe mechanism

C O N T I N U I N G E D U C AT I O N
than one specimen is submitted. In recent years, a number of be ensured that each patient be
Furthermore, a complete and thorough new diagnostic adjuncts have been informed of the result of their biopsy.
description of the lesion should be introduced. These techniques, which The log may also be used to record the
provided. Often, a histopathologic include cytologic sampling and action taken in response to the result.
diagnosis is based on the provision illumination devices, are designed
of accurate clinical information. For strictly as screening tools for the
example, the histology of a dentigerous assessment of suspected premalignant
cyst is non-specific and in the presence and malignant mucosal lesions. They
of some inflammation may simulate are not substitutes for a scalpel biopsy.
a periapical cyst. However, in the Furthermore, given the significant
presence of accurate clinical and potential for false positive results, their
radiographic information (radiolucency findings should be interpreted with
around the crown of an impacted tooth caution.3, 4
#17), the diagnosis of a dentigerous cyst Exfoliative cytology may be a
is confidently made. useful diagnostic tool in clinical
Clinicians may desire to know if practice. This technique harvests
a lesion has been adequately excised. mucosal cells by means of brushing
It is possible to assess adequacy of or scraping, which are then examined
removal if the tissue sample is firstly microscopically. Suspected cases of
removed in one piece. Adequacy of candidiasis can be rapidly confirmed
clear margins may be screened for through oral cytology. In addition,
if the tissue is appropriately tagged herpetic lesions sampled within the first
with sutures. At least two adjoining 72 hours of appearance will often show
margins must be clearly identified diagnostic cytologic features. Lesions
to ensure correct orientation once of pemphigus vulgaris may show the
the specimen is received in the characteristic Tzanck cells. However,
laboratory. For example, a short cytology is not a substitute for scalpel
suture may indicate the anterior aspect biopsy and direct immunofluorescence
of a biopsy specimen, with a longer in the diagnosis of pemphigus vulgaris.
suture indicating the superior aspect The utility of oral cytology in the
(Fig.3). Or, the clinician may mark the diagnosis or screening of suspected
specimen with one suture at one site premalignant or malignant lesions is
and two sutures at another site. After limited. Sampling error frequently
suture placement, the significance results in specimens of little diagnostic
of each must be clearly indicated on value.3, 4 For lesions that are suspicious
the history sheet. By providing this for malignancy or premalignancy, or
information to the pathologist, it is for clinical changes of undetermined
possible to assess anterior, posterior, significance, a biopsy should be
superior and inferior margins (or performed as soon as clinically feasible.
medial and lateral, depending on
the biopsy site), allowing for the Conclusion
identification of areas that might Ultimately, the screening tool
require further excision. Adequacy of of greatest benefit is careful oral
removal may be impossible to interpret examination and sound clinical
if the specimen is fragmented. judgment. The clinician’s knowledge
Mucosal biopsies that are superficial and training may eliminate the need
and that typically do not include for biopsy in cases where lesions are
underlying muscle tissue tend to curl clinically definable. For entities of
and distort. This creates some difficulty uncertain significance or etiology, a
in proper measurement and orientation biopsy provides the simplest and most
of the specimen for tissue processing. rapid means of obtaining the definitive
This may be overcome by immediately diagnosis. In the interest of the
following the biopsy with spreading patient’s well-being, accurate diagnosis
the specimen flat onto a piece of stiff is of utmost importance. When in
card paper or plastic prior to dropping doubt, one can never go wrong with
it (mounted on the stiff paper or plastic) a biopsy-proven diagnosis. Finally, it
into the formalin fixative. would be prudent that a biopsy log be

90-2 • The Oral Biopsy: Indications, Techniques and Special Considerations 19


References: Dr. Harry H. Mincer is a Professor Dr. Molly S. Rosebush is an
C O N T I N U I N G E D U C AT I O N

1. Rawal YB, Blankenship JA, Mincer HH, Anderson KM. of Oral and Maxillofacial Pathology Assistant Professor of Oral and
Metastatic Adenocarcinoma of the Breast Presenting as
Periodontal Disease. Journal of the Tennessee Dental and Director of Oral and Maxillofacial Maxillofacial Pathology, College of
Association. 2007; 87(2): 11-13. Diagnostic Services, College of Dentistry, University of Tennessee
2. Rawal YB, Anderson KM, Mincer HH, Rawal SY, Tortorich
AL. Langerhans Cell Histiocytosis: A Wolf in Sheep’s
Dentistry, University of Tennessee Health Sciences Center.
Clothing? Journal of the Tennessee Dental Association. 2008; Health Sciences Center.
88(4): 26-30.
3. Kalmar JR. Advances in the Detection and Diagnosis of Oral Dr. Swati Y. Rawal is an Assistant
Precancerous and Cancerous Lesions. Oral Maxillofac Surg
Clin North Am. 2006; 18(4): 465-82.
Professor and Director of the Graduate
4. Lingen MW, Kalmar JR, Karrison T, Speight PM. Critical
Program in Periodontology, College
Evaluation of Diagnostic Aids for the Detection of Oral of Dentistry, University of Tennessee
Cancer. Oral Oncol. 2008; 44(1): 10-22.
Health Science Center.
Dr. K. Mark Anderson is an Dr. Yeshwant B. Rawal is an
Associate Professor of Oral and Assistant Professor of Oral and
Maxillofacial Pathology, College of Maxillofacial Pathology, College of
Dentistry, University of Tennessee Dentistry, University of Tennessee
Sciences Center. Health Sciences Center.

20 Journal of the Tennessee Dental Association • 90-2


C O N T I N U I N G E D U C AT I O N
Questions for Continuing Education Article - CE Exam #19

1. For any unknown lesion or condition of the oral 6. Most bony lesions cannot be diagnosed based on
mucosa, the gold-standard for diagnosis is: their:
a. a radiograph a. radiographic features alone
b. an MRI b. pain profile and histopathology
c. a scalpel biopsy c. cortical expansion and histopathology
d. a post-mortem d. all the above

2. A clinician should biopsy an unknown lesion that 7. Hard tissue lesions that warrant biopsy and
does not respond to treatment in: histopathologic examination are:
a. a month a. Expansive
b. a year b. Painful
c. two weeks c. Those producing paresthesia
d. six weeks d. All the above

3. Lesions exhibiting the following conditions should 8. Specimens that are difficult to orient properly for
be biopsied: sectioning are those which:
a. Leukoplakia a. are too small
b. Erythoplakia b. are fragmented
c. Persistent ulceration c. are of inadequate depth
d. All the above d. all the above

4. Unknown submucosal lesions that have no 9. The best instrumentation for acquisition of tissue
diagnostic color or surface changes should: samples is:
a. undergo a scalpel biopsy a. a scalpel biopsy
b. be treated with silver nitrate b. by laser
c. have a needle biopsy c. by electrocautery
d. no biopsy is necessary d. by hi-volume suction

5. All tissue removed from a patient should be: 10. When a biopsy is taken from the oral cavity, what is
a. properly submitted for histopathologic imperative:
examination a. immediate immersion into a proper fixative
b. discarded in a biohazard container placed in b. placed on ice
isopropyl alcohol c. placed on a 2 X 2 gauze square (filled)
c. incinerated d. placed in India ink
d. placed on ice

90-2 • The Oral Biopsy: Indications, Techniques and Special Considerations Exam Questions 21
C O N T I N U I N G E D U C AT I O N

Answer Form for TDA CE Credit Exam #19:


The Oral Biopsy: Indications, Techniques and Special Considerations
Circle the correct letter answer for each CE Exam question:

1. a b c d 6. a b c d

T 2. a b c d 7. a b c d
D
3. a b c d 8. a b c d
A
4. a b c d 9. a b c d
EXAM #19
5. a b c d 10. a b c d

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22 Journal of the Tennessee Dental Association • 90-2