PRINCIPLES OF DIFFERENTIAL DIAGNOSIS AND BIOPSY IN ORAL SURGERY

Presented by Noveen Nabeel Mirza Noor-ul-Sabah Hussain Nadia Mureed Muhammad Usman Iqbal

EXAMINATION AND DIAGNOSTIC METHODS

STEPS TO DIAGNOSE AN ORAL LESION

A detailed health history A history of the specific lesion A clinical examination A radiographic examination Laboratory investigations Surgical specimens for histopathologic evaluation

HEALTH HISTORY

HISTORY OF LESION

QUESTIONS TO ASK
Duration of the lesion Changes in size and rate of change Changes in the character of the lesion.

Lump to ulcer, etc fever nausea anorexia

Associated systemic symptoms:

Symptoms associated with the lesion?

Pain

Acute or chronic Constant or intermittent

Altered function Anesthesia or paresthesia Dysphagia Painful cervical lymph nodes

Anatomic locations involved Historical event associated with lesions e.g trauma,exposure to toxins,allergens Associated systemic symptoms

Fever Nausea Malaise

CLINICAL EXAMINATION

An examination is classically described as including:

Inspection Palpation Percussion Auscultation

PALPATION

CONSIDERATIONS DURING INSPECTIONS

The anatomic location of the lesion/mass The physical character of the lesion/mass The size and shape of the lesion/mass Single vs. multiple lesions The surface of the lesion The color of the lesion The sharpness of the boundaries of the lesion The consistency of the lesion to palpation Presence of pulsation Lymph node examination

RADIOGRAPHIC EXAMINATION

RADIOGRAPHIC EXAMINATION
Provide clues that will help determine the nature of the lesion. A radiolucency with sharp borders will often be a cyst A ragged radiolucency will often be a more aggressive lesion

BIOPSY

Removal of tissue from a living body for the purpose of microscopic diagnostic examination.

INDICATIONS OF BIOPSY
Any inflammatory lesion that does not respond to local treatment after 10 to 14 days without any identifiable cause Visible or palpable submucosal swelling beneath clinically normal mucosa.

Intrabony lesions that appear to be enlarging. Any lesion that has the characteristics of malignancy. Any lesion in a high-risk areas for development of cancer e.g floor of mouth or tongue

Any lesion that is the basis of cancer phobia in a patient.

Confirmation of clinical diagnostic suspicion.

CHARACTERISTICS OF MALIGNANCY

Erythroplasia- lesion is totally red or has a speckled red appearance. Ulceration- lesion is ulcerated or presents as an ulcer. Duration- lesion has persisted for more than two weeks.

Growth rate- lesion exhibits rapid growth Bleeding- lesion bleeds on gentle manipulation Induration- lesion and surrounding tissue is firm to the touch Fixation- lesion feels attached to adjacent structures

CONTRAINDICATIONS FOR BIOPSY

Uncontrolled bleeding diasthasis Anticoagulant therapy Over-whelming sepsis Severe impaired lung function Uncooperative patient Local infection near the site

TYPES OF BIOPSY
Oral

cytology Aspiration biopsy Incisional biopsy Excisional biopsy Needle biopsy

CYTOLOGIC BIOPSY

To monitor large tissue areas for dysplastic changes. Non invasive in nature. Has two main forms of tests that are used clinically. Exfoliative cytologic examination Oral brush cytologic examination.

1.
2.

Hand held rotary brush

EXFOLIATIVE CYTOLOGIC EXAMINATION

Used for detection of cervical uterine cancer Not reliable in diagnosing oral and maxillofacilal lesions Gives false negative results

ORAL BRUSH CYTOLOGIC EXAMINATION

Superior to exfoliative cytologic examination

Indications:

Non invasive tool for monitoring patients with chronic mucosal changes e.g leukoplakia. Adjunct for followup of patients with history of oral cancer

TECHNIQUE
Local anesthesia not required Hand held rotary brush is placed in content with the surface of suspected lesion and rotated with firm pressure 5-10 times Cellular material smeared on glass slide Fixative solution added Slide dried Specimen examined under microscope

Brush contacts the tissue and is rotated 5-10 times with moderate pressure

Transfer of cells to a microscopic slide and application of fixative

INTERPRETATIONS

Negative:-no epithelial abnormalities Positive:-definitive dysplastic changes or malignancy present Atypical:- abnormal epithelial changes but not malignant

INCISIONAL BIOPSY

A biopsy procedure that only removes a small portion of a lesion.

If a lesion is large or has different characteristics in various locations more than one area may need to be sampled

INDICATIONS FOR INCISIONAL BIOPSY

Extensive size (>1 cm in diameter) Hazardous location Definitive histopathological diagnosis desired before a complex invasive removal of the lesion

TECHNIQUE

Representative areas of lesion should be incised in wedge fasion Selected in an area that shows complete tissue changes(the lesion extends into normal tissue at the base and/or margin of the lesion)

TECHNIQUE

Necrotic tissue should be avoided Taken from the edge of the lesion to include some normal tissue A deep, narrow biopsy rather than a broad, shallow one

EXCISIONAL BIOPSY
An excisional biopsy implies the complete removal of the lesion.

Indications:
1. 2.

Should be employed with small lesions. Less than 1cm. When complete excision with a 2-3 mm margin of normal tissue is possible without mutilation.

ASPIRATION BIOPSY

Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration if its contents. Indications:
1.
2. 3.

To determine the presents of fluid within a lesion. To a certain the type of fluid within a lesion. When exploration of an intraosseous lesion is indicated

ASPIRATION
An 18 gauge needle on a 5 or 10 ml syringe is inserted into the area under investigation after anesthesia is obtained. The syringe is aspirated and the needle redirected if necessary to find the fluid cavity.

PRINCIPLES OF SURGERY

ANESTHESIA

Block local anesthesia techniques are employed when possible The anesthesic solution should not be injected within the tissue to be removed, because it can cause architectural distortion of the specimen

ANESTHESIA

When blocks are not possible, infiltration of local anesthesia may be used locally, but the solution should be injected at least 1 cm away from the lesion

TISSUE STABILIZATION
Tongue or soft palate --Heavy retractive sutures --Towel clips Lip -- assistants finger pinching the lip on both sides of the biopsy area

HEMOSTASIS
Suction devices should be avoided Gauze compresses are usually adequate Gauze wrapped low volume suction may be used if needed

INCISIONS

Incisions should be made with a scalpel using no.15 blade Should extend beyond the suspected depth of the lesion

They should parallel important structures

INCISIONS

Margins should include 2 to 3mm of normal appearing tissue if the lesion is thought to be benign.

5mm or more may be necessary with lesions that appear malignant, vascular, pigmented, or have diffuse borders

WOUND CLOSURE

Primary closure of the wound is usually possible. In deep lesions resorbable sutures material should be used to close the layers separately

Resorbable Sutures used are polyglycolic acid and chromic gut

The mucosa is undermined for tension free approximation of the tissue margins Elliptical incision on the hard palate or attached gingiva may be left to heal by secondary intention Periodontal dressing placed in tissue

HANDLING OF SPECIMEN

Immediately placed in 10% formalin solution that is at least 20 times the volume of surgical specimen

Totally immersed in the solution

Care should be taken to be sure that the tissue has not become lodged on the wall of the container above the level of the formalin

HANDLING OF SPECIMEN

Direct handling of the lesion will expose it to crush injury resulting in alteration the cellular architecture

MARGIN IDENTIFICATION

Marked with a silk suture to orient the specimen for the pathologist If the lesion is diagnosed as requiring additional treatment, the pathologist can determine which margin, if any had residual

BIOPSY DATA SHEET

A biopsy data sheet should be completed and the specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed

INTRAOSSEOUS (AND HARD TISSSUE )BIOPSY

Intraosseous lesions are most often the result of problems associated with the dentition. If any intraosseous lesion that appears unrelated to the dentition and cannot be characterized radiographically

INTRAOSSEOUS (AND HARD TISSSUE )BIOPSY

Palpation of the area of the lesion with comparison to the opposite side. Any radiolucent lesion should have an aspiration biopsy performed prior to surgical exploration.

Information from the aspiration will provide valuable information about the lesion.
1. 2.

3.
4.

Solid Fluid Filled Vascular Without Contents

PRINCIPLES OF SURGERY
Mucoperiosteal flaps should be designed to allow adequate access for incisional/excisional biopsy. Incisions should be over sound bone Flaps should be full thickness Major neurovascular structures should be avoided

OSSEOUS WINDOW
A small round surgical burr under constant irrigation can be used to create osseous window. Bone removed should be submitted with the specimen Avoid roots and neurovascular structures The size of the lesion will determine the amount of bone removal

PRINCIPLES OF SURGERY
Incisional biopsies only require removal of a section of tissue Soft tissue overlying the lesion should be reapproximated following thorough irrigation of the operative site. The specimen should be handled as previously described