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IN BRIEF
Biopsies of different tissue types and sites require specific techniques.
Correct handling of biopsy specimens is crucial.
The chosen site for a mucosal biopsy is dependent upon the disease/lesion.
Written consent is advised for all biopsies.
VERIFIABLE
CPD PAPER
Oral biopsies: methods and applications
1 2 3
R. J. Oliver P. Sloan and M. N. Pemberton
Biopsies are an important diagnostic tool for the diagnosis of lesions ranging from simple periapical lesions to malignancies.
Planning prior to performing a biopsy is essential. It will be beneficial to the receiving pathologist in reaching a helpful and
meaningful diagnosis, and therefore ultimately and more importantly, to the patient. This paper presents an updated view of
biopsies and discusses some of the potential problems with biopsy technique and specimens and how to overcome them.
A biopsy is often the only way to diagnose avoid them. The authors feel it will be of 4
of submitting material; one respondent
oral lesions and diseases and as with most value to both general dental practitioners cited that the non-submission of material
procedures there is often more than one and junior hospital staff. Problems related often leads to a failure to diagnose and the
method of undertaking the surgery suc- to specific areas will be covered including situation regarding periapical lesions is no
cessfully. Whatever the method used, how- apical lesions and those associated with different, no matter how rare such
ever, the aim is to provide a suitably repre- the dental hard tissues. Mucosal and soft instances occur.
sentative sample for the pathologist to tissue biopsies together with general points For diagnosis, the excised material needs
interpret, while minimising perioperative regarding techniques and fixation will also to be fixed to stop tissue autolysis prior to
discomfort for the patient. An unsuitable, be discussed. the sample reaching the pathology
unrepresentative sample is of no use to the laboratory. The solution of choice to do this
pathologist, clinician or most importantly the SPECIFIC TISSUES is 10% neutral buffered formalin fixative (a
patient who would be ill served by an 4% solution of formaldehyde). This can
unnecessary repeat procedure. Although Apical lesions and those associated easily be obtained on request from most
most biopsies are performed in hospitals, a with the dental hard tissues pathology laboratories together with a sup-
recent study has shown that many general Many apical lesions are submitted routine-ly ply of request forms and specimen pots. In a
dental practitioners felt able to perform from general dental practice as well as 1
recent survey, many practitioners appeared
biopsies but lacked some of the necessary hospitals following periradicular surgery.
1
unaware of these facilities and as such
skills. The purpose of this article is to The majority of the lesions are inflammato- pathology laboratories may need to consider
review those skills, to discuss new develop- ry in origin, most commonly periapical advertising their services more widely. It
ments in this area, and to highlight some of granulomas or radicular cysts. Less com- should be noted that some labo-ratories
the potential pitfalls that may occur in tak- monly, other odontogenic cysts present at the might levy a nominal charge for such
ing a biopsy and methods available to apex, namely nasopalatine duct cyst or of services.
greater significance the odontogenic Some clinicians submit apical lesions
keratocyst. Less frequently still, odonto-
on gauze which has been placed in
1 2
Lecturer in Oral Surgery, Professor of Oral Pathology, genic tumours may present at such a site.
3 formalin solution. However, if the volume
Consultant in Oral Medicine, Oral and Maxillofacial Bone lesions such as Langerhans cell histi-
Sciences, University Dental Hospital of Manchester, Higher
ocytosis, giant cell granuloma and myelo-ma of forma-lin in the container is not great
Cambridge Street, Manchester M15 6FH
may also present in this way. Rarely, enough, the gauze tends to absorb most of
Correspondence to: Dr. Richard Oliver, University Dental
Hospital of Manchester, Higher Cambridge Street, malignant metastatic deposits or even the formalin leaving the specimen dry and
Manchester, M15 6FH intraosseous squamous cell carcinoma can unfixed. Although not essential, it is
E-mail: richard.j.oliver@man.ac.uk 2 desirable to inform the pathologist if bone
occur at this site. The value of routinely
is included in the specimen.
Refereed Paper examining apical lesions has recently been
doi:10.1038/sj.bdj.4811075 3
Occasionally, it is necessary to examine
Received 05.12.02; Accepted 07.07.03 questioned, however, the resulting corre- the dental hard tissues, most often to rule
British Dental Journal 2004; 196: 329333 spondence has all been strongly in support out an abnormality of dentine or enamel.
As with most other tissues submitted for allows confirmation that it is arising from the intact area of mucosa which is often the
routine examination, teeth should also be overlying epithelium rather than from a attached gingiva; an elliptical area of
submitted in 10% neutral buffered formalin deeper structure or from a metastasis from a mucosa is incised and carefully dissected
fixative. A mineralised sample, such as bone different site. It also allows the invasive front from the underlying periosteum with a
or tooth may require decalcification before it to be examined which can yield use-ful Mitchell's trimmer.
can be processed. The time for the 5
prognostic information. The centre of larger
decalcification will vary according to the size tumours should be avoided as this is often Precancerous lesions
and consistency of the specimen as well as necrotic and will not yield diagnostic For the precancerous lesions of leukoplakia
the methods employed by a particu-lar material. A recent study has demonstrated and erythroplakia, the adequate and correct
laboratory, but it should be borne in mind that cytokeratins were present in the sampling of lesions may prove more diffi-
that it can be a matter of weeks before a peripheral blood of two out of ten patients 15 cult. It is now well recognised that lesions
histopathology report is available. minutes after the incisional biopsy of an oral showing a non-homogenous or speckled
squamous cell carcinoma, thereby appearance and lesions of erythroplakia are
Mucosal biopsies demonstrating that there was dissemina-tion potentially more serious with a gener-ally
Biopsy technique for the sampling of of cancer cells which may result in higher incidence of dysplasia and malignant
6 7
mucosal biopsies can be critical. If a metastasis. These authors suggested that transformation. These areas, if present,
tumour or premalignant disease is suspect- chemotherapeutic drugs should be admin- should be the site of choice for biopsy. If the
ed, or when widespread mucosal disease is istered prior to biopsy to minimise the risk of lesion is extensive or there are numerous
suspected, we would strongly advocate the metastasis in such patients. However, the erythematous regions it may be prudent to
biopsy being undertaken in a hospital set- incidence of blood borne metastasis in biopsy more than one area.
ting following appropriate referral; such relation to oral cancer is low, but this area
lesions should not be biopsied in general merits further investigation. Handling of mucosal biopsies
dental practice. Such biopsies should be Care should be exercised when handling
performed by the clinician who is going to Mucocutaneous lesions mucosal biopsy specimens as they can be
initiate the treatment. Some of the follow- Biopsies are commonly taken to confirm the particularly prone to damage. Sometimes
ing section is, therefore, for information clinical diagnosis of lichen planus, lichenoid specimens can be rendered of little diag-
for general dental practitioners and of reactions or other similar muco-cutaneous nostic value due to poor handling which
more relevance to junior hospital staff. conditions. To aid in the histo-logical produce a crush artefact in histological
Simple excisional biopsies of polyps or diagnosis of such lesions, an area of non- section. There are various methods avail-
epulides are suitable for general dental erosive lesional tissue should be cho-sen. able to reduce traumatic damage to the
practice, and can be both diagnostic and Sampling of an erosive area will often show specimens.
curative at the same time. Before embark- non-specific inflammatory changes A popular method is to place a suture
ing on a biopsy the question of what the associated with ulceration and will not aid in within the mucosa that is to be removed,
biopsy is being taken for must be the diagnosis. Adjacent normal tissue is not and hold the ends of the suture in an artery
answered (Table 1). The provisional generally required for such lesions. Similarly forcep or sometimes tie a loose knot above
clinical diagno-sis is especially important for suspected vesiculobullous disorders, the the mucosa, while undertaking the biopsy.
in guiding the technique and tissue site of the biopsy should be adjacent to bulla A tight knot close to the specimen,
handling to be used (Table 2). where the epithelium is still intact. For these however, is to be avoided as it may result
lesions it is desirable also for the laboratory in the tissue being crushed. The use of
Suspected malignancy to receive a fresh specimen of tissue in such a suture can aid the biopsy procedure
If the reason for the biopsy was to exclude addition to a formalin fixed one to allow by providing traction and preventing
malignancy in a long-standing ulcer, a direct immunofluores-cence (see later unwanted movement of tissue when tak-
biopsy of the ulcer to include some adja- regarding fresh specimens). When ing a biopsy from mobile structures such
cent clinically normal epithelium would be desquamative gingivitis is present, the biopsy as the tongue. It also helps the pathologist
desirable. If the lesion is a carcinoma this should be taken from the most to orientate the biopsy sample for section-
ing. The traditional technique using
toothed tissue forceps to grasp the speci-
Table 1 Points to consider prior to mucosal biopsy men is acceptable providing care is taken
and the area grasped is away from the
1. Why is biopsy being taken? Eg to confirm a mucosal disease main site of interest.
such as lichen planus or to exclude malignancy. The punch biopsy technique is an alter-
8
2. What information is required from the pathologist? Eg native to the traditional incisional biopsy.
is the lesion completely excised. Essentially the punch comprises a circular
blade attached to a plastic handle. Diame-ters
3. Is the biopsy to exclude malignancy? Therefore take the biopsy
from the edge of the lesion of two to ten millimetres are available. This
removes a core of tissue the base of which
4. Is the biopsy incisional or excisional? Eg For excisional biopsies can be simply and atraumatically released
a margin of surrounding normal tissue will be required. using curved scissors. Alternative-ly, the
5. Will the specimen be required to be orientated? This is important for excisional specimen can be lifted from the mucosal
biopsies so that if residual tumour is left or the excision is close to the margin, surface and the base undermined with a
the surgeon knows where to perform a re-excision if necessary. scalpel. Care should be taken if aspi-ration is
being used to prevent the speci-men being
6. Is a fresh specimen required? For vesiculobullous lesions these
sucked away. The resultant wound may not
are often required for direct immunofluorescence. They are also
used if a rapid diagnosis is required. require suturing if using the smaller diameter
punches. This tech-nique is described and
reviewed in detail by
patients particularly in general dental 11. Kerawala C J. Incisional biopsy: reducing artefact. Br J
dent histological diagnosis to be reached.
practice (Dental Protection, personal com- Oral Maxillofac Surg 1995; 33: 396.
Inadequate care at any stage could result 12. Staines K, Felix D H. Surgical emphysema:
munication). It would be appropriate to in a non-diagnostic biopsy and may an unusual complication of punch biopsy.
include on the consent form the indication necessitate the patient having a repeat Oral Diseases 1998; 4: 41-42.
for the biopsy and details of possible risks 13. Golden D P, Hooley J R. Oral mucosal biopsy
procedure with its ensuing physical and
procedures. Excisional and incisional. Dent
involved with biopsy procedures. These risks psychological morbidity. Clin North Am 1994; 38: 279-300.
are mostly site related; paraesthesia can be 14. Sciubba J J. Improving detection of precancerous and
induced in the lips or the tongue, swelling 1. Diamanti N, Duxbury A J, Ariyaratnam S, Macfarlane T cancerous oral lesions. Computer-assisted analysis of
V. Attitudes to biopsy procedures in general the oral brush biopsy. J Am Dent Assoc 1999; 130:
and bruising can result from pro-cedures in
dental practice. Br Dent J 2002; 192: 588-592. 1445-1457.
the tongue, lips and buccal mucosa, and 2. Lavery K, Blomquist J E, Awty M D, Stevens 15. Orell S R, Sterrett G F, Waters M N, Whitaker D.
procedures in the floor of the mouth can lead P J. Squamous cell carcinoma arising in a Manual and Atlas of Fine Needle Aspiration Cytology.
to submandibular or sub-lingual duct dental cyst. Br Dent J 1987; 162: 259-260. Edinburgh and London: Churchill Livingstone, 1986.
3. Walton R E. Routine histopathologic examination 16. Southam J C, Bradley P F, Musgrove B T. Fine
damage. Removal of muco-coeles from the needle cutting biopsy of lesions of the head and
of endodontic periradicular surgical specimens-is it
lip carries the risk of fur-ther gland damage warranted. Oral Surg Oral Med Oral Pathol Oral neck. Br J Oral Maxillofac Surg 1991; 29: 219-222.
23 Radiol Endod 1998; 86: 505 17. Pearse A G E. The chemistry and practice of fixation. In
and recurrence. Kearns et al. reported a Pearse A G E (Ed) Histochemistry. Theoretical and
4. Baughman R A. To biopsy or not. (Letter). Oral Surg
recent study into pain experience following Oral Med Oral Pathol Oral Radiol Endod 1999; 87: applied. Edinburgh: Churchill Livingstone, 1980:
oral mucosal biop-sies. They concluded that 644-645. 97-158.
18. Shi S R, Cote R J, Taylor C R. Antigen retrieval
most patients did not experience significant 5. Bnkfalvi A, Piffko J. Prognostic and predictive factors
immunohistochemistry: past, present, and future. J
in oral cancer: the role of the invasive tumour front.
pain post-oper-atively and those that did Histochem Cytochem 1997; 45: 327-343.
JOral Pathol Med 2000; 29: 291-298.
were controlled adequately with analgesics; 6. Kinsukawa J, Suefuji Y, Ryu F, Noguchi R, 19. Odell E W, Morgan P R. Practitioner biopsy
most patients' pain reduced after 3 days. It is Iwamoto O, Kameyama T. Dissemination of services. (Letter). Br Dent J 2002; 193: 182.
20. Margarone J E, Natiella J R, Vaughan C D. Artefacts in
important to give the standard post-operative cancer cells into circulation occurs by incisional
oral biopsy specimens. J Oral Maxillofac Surg 1985;
biopsy of oral squamous cell carcinoma. J Oral
oral sur-gery instructions to the patient. 43: 163-172.
Pathol Med 2000; 29: 303-307.
21. Krause L S, Cobb C M, Rapley J W, Kilroy W J,
7. Speight P M, Morgan P R. The natural history
Spencer P. Laser irradiation of bone. I. An in vitro
and pathology of oral cancer and precancer.
study concerning the effects of the CO2 laser on oral
CONCLUSIONS Comm Dent Health 1993; 10 (Suppl 1): 31-41.
mucosa and subadjacent bone. J Periodontol 1997;
8. Eisen D. The oral mucosal punch biopsy. Report of
When considering biopsy a little forward 140 cases. Arch Dermatol 1992; 128: 815-817. 68: 872-880.
planning and thought can greatly improve 22. Medical Devices Agency. Catgut sutures-
9. Lynch D P, Morris L F. The mucosal
cessation of supply. 2001. http://www.medical-
the diagnostic value obtained. Careful punch biopsy: indications and technique.
devices.gov.UK/ catgutsutures.htm
J Am Dent Assoc 1990; 121: 145-149.
handling of the tissue and prompt 10. Moule I, Parsons P A, Irvine G H. Avoiding artefacts in
23. Kearns H P O, McCartan B E, Lamey P-J. Patients'
appropriate fixation will enable a confi- oral biopsies: the punch biopsy versus the incisional
pain experience following oral mucosal biopsy under
local anaesthesia. Br Dent J 2001; 190: 33-35.
biopsy. Br J Oral Maxillofac Surg 1995; 33: 244-247.
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