Oral biopsy procedures practiced in dentistry.

Biopsy or by-op-see or Bx is a method for definitive diagnosis and effective Rx planning protocol and is expanding in dentistry. I hope you will appreciate my work over this PPT, tagged videos will be available across my twitter- @nonstoppresident

1. ORAL BIOPSY PROCEDURES Created & Presented by: Dr. Ronak Varyani

2. CONTENTS Introduction Classification Indications contraindications Objectives Principles Dangers Lasers Artefacts The biopsy report Post Bx instructions

3. Introduction Biopsy in the greek terminology (by-op-see) means bio-Life/living and opsy meaning-to look at. It is defined as surgical removal of a tissue specimen from a living individual for the purpouse of examination and diagnosis. In few cases biopsy can also be therapeutic and in few cases invaluable in management of certain lesions. Historical perspective of biopsy,In 1870 Ruge and Joham vert in Berlin introduced biopsy as an essential tool for diagnosis.

4. 1889,Emarch put forward an arguement that a confirmation should be made clinically on whether a lesion needs a biopsy or not. William Halstead 1st introduced this first time in the united states of america in 1920. 1941, Study of exfoliated cells was done derived from female genital tract,performed by papanicolou. Along with this further advancements and staining methods were introduced and was implemented into studying different parts of the body,One such discrete source being

5. CLASSIFICATION Bx

6. Indications Persistent hyperkeratotic changes in the tissue Lesions interfering with local tissue function. Inflammatory lesion not responding to treatment within 2 weeks. Bone lesions not specified as a normal radiographic finding. Any unknown etiological lesions persisting beyond 2 weeks. Any lesions that have characteristics of malignancy

7. Characterstics of lesions leading to suspicion of malignancy: Growth rate- Rapid and extreme Bleeding- Bleeding with gentle manipulation Induration-Lesion and surrounding tissue is firm to touch Fixation-lesion feels fixed to adjacent tissues erythroplakia- lesion is red and has a speckled apperance Ulceration- presents as an ulcer with margins and borders Duration- lesion has persisted more than 2 weeks

8. Contraindications There is obviously no need to biopsy normal tissues. There is no need to biopsy inflammatory and infectious lesions responding to local and topical treatments. No incisonal biopsies should be performed over suspected angiomatous lesions. No Bx when general health of patient is poor. When acute pathological virulence is present. Pigmented lesions should not be biopsied as they can transform into malignant melanomas on intervention.

9. Not advised to do Bx in neurofibromas due to risk of neurosarcomatous trans- formation or in salivary tissues as they may infiltrate surrounding tissues.

10. Objectives To confirm the clinical diagnosis For medicaln records To determine Rx plan As a self teaching diagnostic aid

11. Principles Choose most suspicious area for Bx. Avoid slough or necrotic areas. Give LA or regional anesthesia around or into lesions Include normal tissue margins also Specimen should at least be 1mm* 0.6mm L-B and 2mm deep Edges should be vertical and not bevelled.

12. Incisional or Wedge Bx If a lesion is large and has different characteristics in different areas then more than one area is to be sampled. Indications- Size Limitation Hazardous location of lesion Great suspicion of malignancy

13. Disadvantages- Crush,Splits and hemorrhage is the most common artefact found in incisional Bx Seeding of Cancer cells into deeper tissues TECHNIQUE- Represented areas are Bx in a wedge fashion Margins should extend into the normal tissue on the deep surface Necrotic tissue to be avoided Narrow deep specimen is better than a thick shallow one.

14. Incision to extend from lesion to normal tissue. gasp area to be held by tissue forceps and area to be elliptically incised and later sutured.

15. Excisonal Bx It implies the complete removal of the lesion,i.e the entire lesion along with 2-3mm of normal apperaing tissue surrounding the lesion if benign. Indications: 1.Should be employed with small lesions,Less than 1 cm. 2.Lesion on clinical exam appears benign. 3. When complete excision with a margin of normal tissue is impossible without mutilation.

16. Excisonal Bx It implies the complete removal of the lesion,i.e the entire lesion along with 2-3mm of normal apperaing tissue surrounding the lesion if benign. Indications: 1.Should be employed with small lesions,Less than 1 cm. 2.Lesion on clinical exam appears benign. 3. When complete excision with a margin of normal tissue is impossible without mutilation.

17. Excisonal Bx

18. Frozen section Bx frozen section technique alows a stained slide to be examined within 10 minutes of taking a specimen. Tissue is sent fresh to the laboratory and is to be quickly frozen at abiut -70 degrees, via immersion in liquid Nitrogen or dry ice. The section is then cut on a refrigerated microtome and stained. Advantage is that it allows greater fixation of the tissues.

19. Frozen section refrigerated microtome

20. Frozen section Bx Advantage- 1. Can establish at operation whether or not a tumor is malignant and whether excision needs to be extended. 2. Can confirm extension margins of a free tumour. Limitations- 1. Freezing by poor technique can disturb the cellular picture. 2. definitive diagnosis sometimes impossible.

21. Fine Needle aspiration Cytology It is the technique of aspiration of cells/fluid/tissue fragments using a fine needle for exaination under a microscope. Indications- -Non palpable lesions or area difficult to access but can be localized by CT,MRI or ultrasound. -To rule out vascular lesions prior to open surgery -In cases where Bx is contraindicated on medical grounds. -Indicated to known tumors and to obtain specific tissues for study.

22. Technique- FNAC with aspiration FNAC without actual aspiration FNAC with aspiration- 1. Site of FNAC should be cleaned with spirit swab. 2. Needle is introduced in swelling and is gently moved to and fro and negative suction is created by withdrawing the piston. 3. Air is taken in syringe and needle is reattatched. 4. Aspiration material is expelled and smear is made by gently pressing the upper slide on lower.

23. Repetedly pressing a needle under negative pressure through the lesion to collect cells.

24. FNAC without Aspiration- -Introduced by Zajdela in 1987. -based on observation that the capillary pressure in a fine needle is sufficient to keep the detached cells of the tumor in the lumen of needle.

25. FNAC without Aspiration-

26. Advantages of FNAC- -Technique is relaitvely painless and gives faster results -requires little equipment -technique can be done as an outpatient or bed side also. -There is no issues with healing due to minimal invasion. - technique is readily repeatable.

27. Core needle/Thick Needle Bx 1. Needle upto 2mm thick is used to remove a core of tissue 2. specimen processed is not like FNAC but like conventional tissue Bx. 3. Larger samples than FNAC preserve the tissue architecture better. 4. definitive diagnosis more likely than FNAC. Limitations- 1. Risk of seeding neoplasm deeper. 2. Risk of damaging anatomical structures.

28. Brush Bx It has been proposed that cytological examination of the tissues is a non invasive method of determining presence of cellular atypia adn hence the likelihood of oral epithelial dysplasia. Technique- A brush is rotated on the lesion with slight pressure several times and is then immedietly smeared on the glass slide and fixed with alcoholic spray.

29. Brush Bx

30. Punch Bx Punch Bx is a primary technique to obtain diagnostic,full thickness tissue specimen It is performed using a circular blade or triphine and attatched to a pencil like handle. various resuable(autocavable) and disposable triphens (punches) are available in the market and are being used judiciously. 4mm,6mm,8mm,10mm punches are available.

31. Exfoliative Cytology It is a quick and easy procedure and an important alternative to Bx in certain situations. In exfoliative cytology cells shed from the body surface such as side of mouth are collected and examined. Indications- 1. Diffuse,large and multiple lesions. 2. Urgent result is required 3. Patient is not indicated for surgery.

32. Technique- Scrap the lesion with a stainless steel spatula or moistened tongue depressor. Cells smeared are transferred on glass slide immedietly.

33. Lasers and Bx L-L ight A-Amplification by S-Stimulated E-Emission of R-Radiation Most commonly used recent advances in lasers are- CO2 lasers and ND YAG lasers. One we use in our deparment is a diode laser developed by BIOLASE.

34. Advantages of lasers- 1. Less pain and less need for LA. 2. Reduction in Pre-operative anxiety. 3.Minimal bleeding and maximum visiblity of feild. 4.Reduce bacterial infections. 5. Preserve more healthy tissue.

35. Disadvantages of lasers- 1. lasers cant be used on teeth with fillings that are already in place. 2. Lasers cannot be used in conditions like large lesions between teeth. 3. Do not eliminate need for LA. 4. Expensive and technique sensitive.

36. Precautions- 1. Use safety goggles due to retinal damage 2. Lock the door during Bx 3.Never look directly into laser beam 4. Never point laser beam at any person except the area. 5. Never stop or bend fiber optic cable. 6.Never move laser machine during Bx.

37. Lasers vs conventional Bx SUBJECT LASERS BX CONVENTIONAL BX ANESTHESIA MINIMAL YES BLEEDING MINIMAL YES TIME LESS TIME MORE TIME PAIN SLIGHT ANESTHESIA DEPENDENT SUTURING NOT REQUIRED REQUIRED IN LARGE LESIONS COST EXPENSIVE MODERATE POST-OP COMPLICATIONS MINIMAL MORE

38. Lasers vs conventional Bx SUBJECT LASER BX CONVENTIONAL BX HEALING RAPID SLOW PATHOLOGY ELIMINATION DEHYDRATION TRAUMATIC REMOVAL DENTIST COMFORT BETTER LESS PROCEDURE SKILLED LESS SKILLED TEAM WORK MORE LESS EXPERIENCE SAME SAME

39. Dangers of Biopsy 1. Spread of Infection. 2. Hemorrhage 3. Operative trauma 4. Seeding of neoplasm deeper or adjacently.

40. Post-Bx instructions 1. Removal of cotton pellet or gauze only after 30-45 minutes after procedure. 2. Slight bleeding may be seen on swab removal,if heavy blleding is seen,consult soon. 3. Application of ice packs to relieve inflammation signs. 4. Avoid hot foods for at least 48-72 hours as it can exacerbate the symptoms of inflammation. 5. Avoid vigorous gargle and chemical irritants as it will avoid clot formation.

41. Post-Bx instructions 6. Avoid use of any tobacco products/alcohol at least for 24 hours after the Bx. 7. If area is sutured,Suture removal to be done after 7 days of wound contraction. 8. Post-Bx antibiotics can be given in few cases,In others,Only analgesics in the right dosage will do a great job.

42. Biopsy Reports: Ideally a biopsy report must include- 1. Name of the clinician 2.Date the specimen was obtained 3.Pertainent characteristics of the specimen histologically. 4.Location,site,size,colour,borders,margins,consistency and relative radiodensity of the lesion.

43. Biopsy Artefacts: Biopsy artefacts- Introducing LA syringe into the lesion can disrupt details. Improper handling of the tissue- 1.Destruction during manipulation 2. heat artefact 3. foreign body artefact 4. starch artefact

44. References 1. Principles of oral and maxillofacial surgery- Neelima Malik 11th edition 2. Oral and maxillofacial surgery by Balaji 3rd edition 3. Oral pathology for students by S. Purkait 7th edition 4. Oral pathology by Shafers 3rd edition 5. S DAS manual of clinical surgery 4th edition 6. Manipal manual of surgery 12th edition 7. Springers Oral lesions and their management. 8. Youtube for surgical video demonstrations.

45. Thank You!