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Klinisi - Biopsy

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

Praktek TegKesGi
Holistic Approach

Health History

An accurate health history may disclose predisposing factors in the disease process or factors that affect the patients management. Up to 90% of systemic diseases can be discovered through history taking. Medical conditions that warrant special care include: Congenital heart defects Coagulopathies Hypertension Poorly controlled diabetics Immunocompromised patients

History of the Lesion

} Duration of the Changes in size and rate of } lesion Changes } change in the character of the lesion. to ulcer, ? Lump etc } Associated systemic symptoms: ? Pain, Swelling, Bleeding, Fever, nausea, anorexia }Evidence of causative factors }Previous treatment

More Questions to Ask

Pain Abnormal sensations Anesthesia A feeling of swelling Bad taste or smell Dysphagia Swelling or tenderness of adjacent lymph nodes } Character of the pain if present

Historical Reasons for the Lesions:

Trauma to the area } Recent toothache } Habits

Clinical Examination
The clinical examination should always include when possible:

Inspection Palpation Percussion Auscultation

Facts about a lesion

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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 Attachement and degree of mobility Presence of pulsation Lymph node examination


Radiographic Examination
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The radiographic appearance may 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 Radiopaque dyes and instruments can help differentiate normal anatomy


Laboratory Investigation
Oral lesions may be manifestations of systemic disease. If a systemic disease is suspected it should be pursued.


Inter-Relationships Between Oral and Systemic Health and Disease



Oral lesions may be manifestations of systemic disease. If a systemic disease is suspected it should be pursued.

These include:
} Tumor of hyperparathyroidism } Padgets disease } Multiple myeloma } Determination of serum calcium,phosphorus, and alkaline phosphatase and protein can be very useful in excluding certain pathological processes.


Indications for Biopsy

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Any lesion that persists for more than 2 weeks with no apparent etiologic basis Any inflammatory lesion that does not respond to local treatment after 10 to 14 days. Persistent hyperkeratotic changes in surface tissues. Any persistent tumescence, either visible or palpable beneath relatively normal tissue. Bone lesions not specifically identified by clinical and radiographic findings Any lesion that has the characteristics of malignancy

Characteristics of lesions that raise the suspicion of malignancy.

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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


What is a Biopsy ?


Types of Biopsy
Oral cytology Aspiration biopsy Incisional biopsy Excisional biopsy Needle biopsy


Oral Cytology
Developed as a diagnostic screening procedure to monitor large tissue areas for dysplastic changes. } Most frequently used to screen for uterine cervix malignancy May be helpful with monitoring postradiation changes, herpes, pemphigus.


Aspiration Biopsy
Aspiration biopsy 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 When exploration of an intraosseous lesion is indicated


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.


Incisional Biopsy

An incisional biopsy is a biopsy 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 be sampled


Incisional Biopsy
Indications: Size limitations Hazardous location of the lesion Great suspicion of malignancy Technique: Representative areas are biopsied in a wedge fashion. Margins should extend into normal tissue on the deep surface. Necrotic tissue should be avoided. A narrow deep specimen is better than a broad shallow one.

Excisional Biopsy
An excisional biposy implies the complete removal of the lesion. Indications: Should be employed with small lesions. Less than 1cm The lesion on clinical exam appears benign. When complete excision with a margin of normal tissue is possible without mutilation.

Excisional Biopsy
Technique: The entire lesion with 2 to 3mm of normal appearing tissue surrounding the lesion is excised if benign.



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Block anesthesia is preferred to infiltration } When blocks are not possible distant infiltration may be used } Never inject directly into the lesion


Tissue Stabilization
Digital stabilization } Specialized retractors/forceps } Retraction sutures } Towel Clips



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


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Incisions should be made with a scalpel. They should be converging Should extend beyond the suspected depth of the lesion They should parallel important structures 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.


Handling of the Tissue Specimen


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


Specimen Care

The specimen should be immediately placed in 10% formalin solution, and be completely immersed.


Margins of the Biopsy


Margins of the tissue should be identified to orient the pathologist. A silk suture is often adequate. Illustrations are also very helpful and should be included.


Surgical Closure
Primary closure of the wound is usually possible } Mucosal undermining may be necessary } Elliptical incision on the hard palate or attached gingiva may be left to heal by secondary intention.


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 Tissue Biopsy


Intraosseous lesions are most often the result of problems associated with the dentition.


Indications for Intraosseous Biopsy

Any intraosseous lesion that fails to respond to routine treatment of the dentition. } Any intraosseous lesion that appears unrelated to the dentition.


Clinical Exam
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. Solid Fluid Filled Vascular Without Contents


Principles of Surgery

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Mucperiosteal flaps should be designed to allow adequate access for incisional/excisional biopsy. Incisions should be over sound bone Cortical perforation must be considered when designing flaps Flaps should be full thickness Major neurovascular structures should be avoided


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


Biopsy Results: What If ?

They dont corroborate your clinical impression Repeat the biopsy!!! Determine if the tissue was looked at by an Oral Pathologist

The results show malignancy


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