biopsy 000
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Principles and Techniques ofPrinciples and Techniques of
BiopsyBiopsy
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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.
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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
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$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.
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Medical conditions thatMedical conditions that
warrant special care include:warrant special care include:*ongenital heart defects
*oagulopathies
$ypertension
Poorly controlled dia"etics
Immunocompromised patients
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$istory of the !esion$istory of the !esion
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+uestions to s) +uestions to s)
,uration of the lesion
*hanges in si-e and rate of change
*hanges in the character of the lesion.
– !ump to ulcer etc
ssociated systemic symptoms:
– fever
– nausea
– anorexia
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More +uestions to s) More +uestions to s)
Pain
"normal sensations
nesthesia feeling of swelling
Bad taste or smell
,ysphagia#welling or tenderness of ad/acent lymph
nodes
*haracter of the pain if present
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$istorical 0easons for the$istorical 0easons for the
!esions:!esions:Trauma to the area
0ecent toothache
$a"its
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*linical 1xamination*linical 1xamination
The clinical examination should always
include when possi"le:
– Inspection
– Palpation
– Percussion
– uscultation
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*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
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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
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!a"oratory Investigation!a"oratory Investigation
Oral lesions may "e manifestations of
systemic disease.
If a systemic disease is suspected it
should "e pursued.
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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.
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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.
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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
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*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
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9hat is a Biopsy9hat is a Biopsy
Biopsy is the removal of tissue for the
purpose of diagnostic examination.
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Types of BiopsyTypes of Biopsy
Oral cytology
spiration "iopsy
Incisional "iopsy
1xcisional "iopsy
;eedle "iopsy
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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.
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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.
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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
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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.
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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
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Incisional BiopsyIncisional Biopsy
Indications:
– #i-e limitations
– $a-ardous location of the lesion
– 7reat suspicion of malignancy
Technique:
– 0epresentative areas are "iopsied in a wedge fashion.
– Margins should extend into normal tissue on the deep
surface.
– ;ecrotic tissue should "e avoided.
– narrow deep specimen is "etter than a "road shallow
one.
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1xcisional Biopsy1xcisional Biopsy
n excisional "iposy implies the complete removal of
the lesion.
Indications: – #hould "e employed with small lesions. !ess than 4cm
– The lesion on clinical exam appears "enign.
– 9hen complete excision with a margin of normal tissue is
possi"le without mutilation.
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1xcisional Biopsy1xcisional Biopsy
Technique:
– The entire lesion with 3 to >mm of normal
appearing tissue surrounding the lesion is excisedif "enign.
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Principles of #urgeryPrinciples of #urgery
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nesthesianesthesia
Bloc) anesthesia is preferred to
infiltration
9hen "loc)s are not possi"le distant
infiltration may "e used
;ever in/ect directly into the lesion
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Tissue #ta"ili-ationTissue #ta"ili-ation
,igital sta"ili-ation
#peciali-ed retractors2forceps
0etraction sutures
Towel *lips
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$emostasis$emostasis
#uction devices should "e avoided
7au-e compresses are usually adequate
7au-e wrapped low volume suction may
"e used if needed
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IncisionsIncisions
Incisions should "e made with a scalpel.
They should "e converging
#hould extend "eyond the suspected depth of the lesion
They should parallel important structures
Margins should include 3 to >mm of normal appearing
tissue if the lesion is thought to "e "enign.
=mm or more may "e necessary with lesions that appearmalignant vascular pigmented or have diffuse "orders.
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$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.
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#pecimen *are#pecimen *are
The specimen should "e immediately
placed in 4'( formalin solution and "e
completely immersed.
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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.
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#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.
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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.
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Intraosseous and $ard TissueIntraosseous and $ard Tissue
BiopsyBiopsyIntraosseous lesions are most often the
result of pro"lems associated with the
dentition.
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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.
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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
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Principles of #urgeryPrinciples of #urgery
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
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Principles of #urgeryPrinciples of #urgery
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
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Principles of #urgeryPrinciples of #urgery
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
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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
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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
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