Category Archives: Principles of Differential Diagnosis and Biopsy

REFERRALS FOR BIOPSY

REFERRALS FOR BIOPSY

As with any dental procedure, clinicians vary ‘in their surgical interests and skills. Some dentists are- adept and comfortable in performing almost any biopsy on their patients, whereas others refer all lesions. This variation
has as much to do with’ personal preferences as it does with level of skills. However, the dentist may use certain criteria to determine which biopsies to perform personally and which to refer. These can be summarized into the
following categories.
Health of Patient
Dentists frequently encounter patients who have systemic condi,tions or disease processes that make any surgical treatment either difficult to perform or a hazard to the patient’s health. Several system it conditions discussed in Chapters 1 and 2 complicate routine surgical procedures. If the dentist feels uncomfortable about or unprepared for managing patients who require special medical precautions, referral should not be delayed.

Surgical Difficulty
Biopsies vary in surgical difficulty, If any of the basic surgical principles outlined in Chapter 3 (e.g., access, lighting, anesthesia, tissue stabilization) are problematic to achieve in a given patient, the biopsy procedure is more
complicated. Similarly, as the size of the lesion increases, , as its position encroaches on normal anatomic structures, and as its potential for surgical complications (e.g., bleeding) increases, so does the difficulty of biopsy. Each dentist must decide whether the indicated biopsy is within
the general scope of his or her surgical skills. If not it should be referred.

Potential for Malignancy
The dentist who suspects malignancy has two choices. First, a biopsy can be performed after a thorough clinical examination, including examination of regional lymph nodes. Secondly, the patient can be referred before biopsy to a clinician who can treat the patient definitively in the event that the lesion is malignant. This latter choice may provide better service if the clinician who treats the patient definitively can see the patient  mmediately. It is much easier for this clinician to evaluate the lesion thoroughly before surgical manipulation. Biopsy can distort
the lesion locally and produce palpable, inflamed lymph nodes. Allowing the clinician to evaluate the patient before biopsy may improve the initial data base and allow a more accurate diagnosis-and formulation of treatrnent. However, if a dentist works in an area where the patient
must travel a long distance to see a clinician who can provide definitive treatment or the clinician -cannot be seen for several days, biopsy should not be delayed.

INTRAOSSEOUS, OR HARD TISSUE BIOPSY TECHNIQUE AND SURGICAL PRINCIPLES

INTRAOSSEOUS, OR HARD TISSUE BIOPSY TECHNIQUE AND SURGICAL PRINCIPLES

A lesion either on or within i:be osseous tissues of the jaws requires investigation. Frequently, problems related to the dentition are the primary cause” and osseous  lesions resolve withroper treatment. However,
any lesion that seems unrelated to the dentition or does not respond to the customary treatment of the dentition should have tissue removed for definitive diagnosis.
The most’ common tntraosseous lesions the dentist wil lencounter are perias and cysts of the jaws. Because these have a ristiphic appearance and ale usually as-ymptoma.tic,: a presumptive,dialnosisis frequently How Crystal, treatment mayinvolve:surgical removal Of.the cyJt in the. form of an, .excisional biopsy. When alesion is large, perforating intosoft tissues, or Suspected of malignancy, tnctsional biopsy ,is indicated.

Hard tissue biopsies are no different in their surgical and pathologic principles from soft tissue biopsies; however, their location mandates some special considerations.

Aspiration Biopsy of Radiolucent Lesions
Any radiolucent lesion that requires biopsy should under go aspiration before surgical exploration. This provides the dentist with valuable diagnostic information regarding the nature of the lesion. The results of aspiration may make the dentist decide to refer the patient to another clinician. For example, brisk, pulsating blood may indicate
a vascular’ lesion; whiCh should not undergo surgical exploration by the general dentist. The return of strawcolored fluid would corroborate the presumptive dtagnosis of a cyst, and surgical removal can then be undertaken without hesitation. The aspiration of air may indicate
that the needle tip is within the maxillary sinus or a traumatic bone cavity. The ‘technique for aspiration was ‘outlined previously.

Mucoperiosteal Flaps
Because of their ‘location within or proximal to the jaws, most lesions of hard tissue must be approached through . a mucoperiosteal flap. Several varieties of mucoperiosteal flaps are available; the choice depends chiefly on the size’ andlpcatton of the lesion.

 FIG 21-13

FIG 21-13

The principles of flap design outlined in Chapter 8 are the same for surgery for an impacted tooth or an osseous biopsy. The size of the lesion dictates how much access is necessary when excisional biopsy is indicated. Access
may necessitate extension of the mucoperiosteal flap. The location of the lesion dictates where the flap incisions are to be made. It is important to avoid major neurovascular structures when-possible and to keep incisionover  sound bone for closure, Optimally the flap design
should provide 4 to 5 mm of sound bone around the anticipated surgical margins. A central lesion that may ‘have eroded the cortical plate of the jaw ‘is- always approached with flap elevation in an area away from the
lesion and.over sound bone. This technique allows establishment of the proper tissue plane for dissection. As the lesion is approached, fusion of the periosteum to the expanding lesion can more readily be ascertained. All
mucoperiosteal flaps for biopsies in or on the jaws sbould be full thickness and incised through mucosa, subrnucosa, and periosteum. The dissection to expose the bone is always performed subperiosteally.

Osseous Window
Lesions within the jaws (i.e., central lesions) require the use of a cortical window. If expansion of iI central lesion has eroded the cortical plate to the point that an osseous void is seen once the flap has been elevated, this window

FIG. 21- 14 Illustrations demonstrating enucleation of cyst. A, Mild swelling in area of periapical cyst. B, Mucoperiosteal flap is elevated from around necks of teeth, and bur is used to remove thinned cortical bone overlying cyst Care is taken to prevent rupturing cystic contents during this and following steps. C and 0; Spoon type of curette is used to strip cyst from bone. Note concave side of curette is kept in contact with bone. Convex surface 1S working end of instrument. E, Clos~re.

FIG. 21- 14 Illustrations demonstrating enucleation of cyst. A, Mild swelling in area of periapical cyst.
B, Mucoperiosteal flap is elevated from around necks of teeth, and bur is used to remove thinned cortical
bone overlying cyst Care is taken to prevent rupturing cystic contents during this and following
steps. C and 0; Spoon type of curette is used to strip cyst from bone. Note concave side of curette is
kept in contact with bone. Convex surface 1S working end of instrument. E, Clos~re.

(if necessary) can be enlarged with rongeurs or burs. If the cortical plate is intact, a rotating bur should be used to remove an osseous window (fig. 21-14). The size of the window depends on the size of the lesion and the proxirr. iry of the window to normal anatomic structures such as roots and neurovascular bundles. Once the window has been created, it can be enlarged with a rongeur. The osseous window specimens should always be submitted for histopathologic examination along with the primary
specimen.

Removal of Specimen
The technique for removal of the biopsy specimen depends on the nature of the biopsy. (excisional versus incisional) and the consistency of the tissue encountered.  Most small lesions that have a connective tissue capsule’ (e.g., cysts) ca be removed in their entirety. A dental
curette i used to peel the connective tissue wall of the specimen from surrounding bone. The concave surface of the instrument should always be kept in contact with the osseous surfaces of the bone cavity (see Fig. 21-14).

Specimen care 
The specimen should be handled exactly as outlined for soft tissue biopsies. The pathologist should be made aware that both hard and soft tissues have been submitted. Radiographs should always b~ included with the
specimen. It may take 2 weeks or longer before the pathology
report is available because of the delay required for decalcification of tissue, For any benign process excised with the biopsy procedure, the dentist must follow the patient – with serial radiographs to monitor osseous healing. In a .lesion that had only an incisional biopsy performed or in ‘
a lesion that requires further intervention, the dentist must see that definitive treatment of the lesion (if necessary) is undertaken.

SOFT TISSUE BIOPSY TECHNIQUE AND SURGICAL PRINCIPLES

SOFT TISSUE BIOPSY TECHNIQUE AND SURGICAL PRINCIPLES

Oral soft tissue biopsy is a.technique that every dentist should be competent to perform. Performed properly, it is a simple and painless procedure that can be done quickiy in the dental office with common, simple instrumentfttion
(8()11( 21-1). The entire oral mUCUSJi~ amenable to biopsy, and the technique only diff~r~ ;lL(“~rdJng W 1(1(“;)\ anatomy and the size and type of ksion.
The surgical principles presented ill (:hdptt>r 3 apply’to biopsy technique, as well as tn an: (.rhu,>lIlgical procedure within the oral cavity. rhe~1.:.’rjnllple~ are briefly outlined in the following sections.

BOX 21-1

Armamentarium for Biopsy
Instruments for Soft Tissue Biopsy
• Local anesthetic equipment
• Scalpel (no. 15 blade)
• Scissors with pointed tips
• Fine tissue forceps
• Small hemostat
• Gauze sponges (suction, if necessary)
• Needle holder, needle, and suture
• Biopsy bottle containing 10% formalin
• Biopsy data sheet’
Additional Instruments for Hard TISsue Biopsy
or Biopsy of Soft TIssue within Bone
• Periosteal elevator
• Rongeur
• Bur and rotary handpiece
• Sterile saline irrigation
• Curettes ~
Instruments for Aspiration of Intraosseous Lesion
• Syringe (5 or 10 ml) .
• Needle (18 gauge) .

Anesthesia
Block local anesthetic techniques are used when possible. The anesthetic solution-should not be injected within the tissues to be removed, because it can cause artifactual distortion of the specimen. When blocks are not possible, infiltration of local anesthetic may be used, but the solution
should be injected at least 1 cm away from the lesion (i.e., field block).

TIssue Stabilization 

Soft tissue biopsies in the oral cavity are frequently performed on movable structures, such as the lips, soft palate, and tongue. Accurate surgical incisions are easiest to perform on tissues that are properly stabilized. Several methods are available in the dental office to achieve tissuestabilization. An assistant’s fingers pinching the lip on both sides of the biopsy area can immobilize the lips (Fig. 21-6, A). This method also aids in hemostasis by compressing the labial arteries. Instruments are available
to perform this same function (Fig. 21-6, B). Heavy retraction sutures or towel clips can be used to aid immobilization of the tongue or soft palate (Fig. 21-6, C). When used, the sutures should be placed deeply into the substance of the tissue, away from the proposed biopsy site.
In this \vay they will be useful for secure stabilization, without pulling through. the tissues.

Hemostasis
The use o.f a suction device for aspiration of surgical hemorrhage
dUrIng bIOP)Y should be avoided. This is especially true’ lIt the high-volume evacuators available in The use o.f a suction device for aspiration of surgical hemorrhage dUrIng bIOP)Y should be avoided. This is especially true’ lIt the high-volume evacuators available in most dental offices. Small surgical specimens can he easily aspirated into these devices and lost. Gauze wrapped over the tip of a low-volume suction device or simple gauze compresses are adequate in most cases, unless
severe hemorrhage is encountered.

Incision
A sharp scalpel should be used to incise tissues for biopsy. The use of electrosurgical equipment is much less desirable. This equipment causes destruction of tissue adjacent to the incision line and may distort the histologic architecture of the specimen. The use of a carbon dioxide laser in the’ super-pulsed mode with a small, wellfocused beam can be used, but the clinician must realize that there will be a thin zone of necrosis from the laser. The advantage of using a laser is that hemostasis is immediately
achieved. Two incisions forming an ellipse at the surface and converging to form a V at the base of the lesion provide a good specimen and leave a wound that is easy to close (Fig. 21-7).

Handling of Tissue
Any tissue specimen removed must be in a condition that readily lends to histopathologic examination. Crushed specimens may be nondiagnostic and only delay definitive diagnosis and therapy because of the necessity of performing a repeat biopsy. Extreme care must be exercised
when removing the surgical specimens. Liberal use of tissue forceps on the specimen will severely damage the cellular architecture, especially in small biopsies. Once a tissue forceps is applied to the specimen, repeated releasing and replacing of the instrument should be avoided. The
use of a traction suture through the specimen is an excellent method for avoiding specimen trauma (fig. 21- J()).

Identification of Surgical Margins
when anytfting but a benign process is suspected. the clinician should mark the margins of the biopsv spcci-

23-6

23-6

FIG. 21-6-cont'd F, Stilbilization of tissue with I1leChaniclildevice. G, Stabilization of tissue with tr.action sutures. "T:wosilk sutures are used t;stabilize.i~gue.before excisional biopsy. They are placed through substance of tongue. (both mucosa and muscle) to prevent pulHng through tissue, H, LesioQ is removed after elliptic incision was made around it. I, Resorbable sutures are placed to approximate muscle. J, M.ucosa is closed.

FIG. 21-6-cont’d F, Stilbilization of tissue with I1leChaniclildevice. G, Stabilization of tissue with
tr.action sutures. “T:wosilk sutures are used t;stabilize.i~gue.before excisional biopsy. They are placed
through substance of tongue. (both mucosa and muscle) to prevent pulHng through tissue, H, LesioQ
is removed after elliptic incision was made around it. I, Resorbable sutures are placed to approximate
muscle. J, M.ucosa is closed.

FIG. 21-7 Illustration of excis~aI biopsy of soft tissue lesion. A, SurfaGe~. Elliptic incision ismade _- around lesion, at teast 3 mITtaway frill"! Jesien. ,I, Side view. tncision is made deep enough to remove lesion completely. C, End view. Incisior;lsare made convergent to depth of wound. If excision is made in this W;)y,closure wIll be facilitated.

FIG. 21-7 Illustration of excis~aI biopsy of soft tissue lesion. A, SurfaGe~. Elliptic incision ismade _-
around lesion, at teast 3 mITtaway frill”! Jesien. ,I, Side view. tncision is made deep enough to remove
lesion completely. C, End view. Incisior;lsare made convergent to depth of wound. If excision is made
in this W;)y,closure wIll be facilitated.

FIG. 21-8 A, illustration .showinq desirability of obtaining deep specimen rather than broad and shallow specimen when incisional biopsy is performed. If malignant cells are present only at base of lesion, broad and shallow biopsy might not obtain these diagnostic cells. B, Illustration showing desirability of obtaining incisional biopsy at margin of soft tissue lesion. Junction of lesion with normal tissue frequently provides pathologist with more diagnostic information than if biopsy were taken only from

FIG. 21-8 A, illustration .showinq desirability of obtaining deep specimen rather than broad and shallow
specimen when incisional biopsy is performed. If malignant cells are present only at base of lesion,
broad and shallow biopsy might not obtain these diagnostic cells. B, Illustration showing desirability
of obtaining incisional biopsy at margin of soft tissue lesion. Junction of lesion with normal tissue frequently
provides pathologist with more diagnostic information than if biopsy were taken only from

FIG 21-9 AND FLG 21-10

FIG 21-9 AND FLG 21-10

 

FIG. 21-11 Illustration showing principles used in closing en eliptic biopsy wound. Mucosa should be undermined pluntly with scissors to widr1!r'<of at/ginal ellipse in each direction. 'This allows appr~iOfl of-wound margins without tension.

FIG. 21-11 Illustration showing principles used in closing en eliptic biopsy wound.
Mucosa should be undermined pluntly with scissors to widr1!r’direction. ‘This allows appr~iOfl of-wound margins without tension.

Specimen Care
After removal the tissue should be immediately placed in 10% formalin solution (4% formaldehyde) that is at least 20 times the volume of the surgical specimen. The tissue must. be immersed in the solution, and care should be taken tobe sure that the tissue has not become lodged on
the wall of the container above the l.

Surgical Closure
Once the specimen is removed, primary closure of the elliptic wound is usually possible. The mucosa is undermined first by placing the closed tips of pointed scissors well into the submucosal area and spreading the tissues
by opening the stissor tips (Fig. 21-11). The submucosa is loose tissue that allows the mucosa to be easily undermined. The extent to which the margins should be undermined depends on the anatomic location and size
of the wound. In the lip, cheek, floor of mouth, and softpalate, undermining of the wound margins by at least the width of the ellipse in each direction is easily performed and allows approximation of the tissues with little tension on the suture line, The incision is then dosed with j~st eno gh sutures to obtain primary closure. Elliptic incisions on attached mucosal surfaces, such as gingiva. and palate, are not closed but rather allowed to heal by secondary intention. Periodontal dressings can be applied
Once the specimen is removed, primary closure of the elliptic wound is usually possible. The mucosa is undermined first by placing the closed tips of pointed scissors well into the submucosal area and spreading the tissues
by opening the stissor tips (Fig. 21-11). The submucosa is loose tissue that allows the mucosa to be easily undermined. The extent to which the margins should be undermined depends on the anatomic location and size
of the wound. In th  lip, cheek, floor of mouth, and soft
palate, undermining of the wound margins by at least the  idth of the ellipse in each direction is easily performed and allows approximation of the tissues with little tension on the suture line, The incision is then dosed with
j~st enough sutures to ob ain primary closure. Elliptic incisions on attached muc sal surfaces, such as gingiva and palate, are not closed but rather allowed to heal bysecondary intention. Periodontal dressings can be applied

FIG, 21-12 A. Biopsy data sheet. Such sheets vary .from one laboratory to the next; the one. listed here represents several. Information provided on this data. sheet descnbeslesion shown in Figure 21-13.

FIG, 21-12 A. Biopsy data sheet. Such sheets vary .from one laboratory to the next; the one. listed
here represents several. Information provided on this data. sheet descnbeslesion shown in Figure
21-13.

Biopsy Data Sheet
All specimens must be carefully labeled and identified
with demographic data of both the patient and the dentist’s
office on a biopsy data sheet (Fig. i1·12). The pathology
laboratory will supply the dentist with specimen bottles
and the biopsy data sheet. All pertinent history and a
clinical description of the lesion must be conveyed t9the
pathologist on this. form. Because radrograpns tof the’
lesion are useful to the pathologist when deahng with

,FIG.. 21-12-cont'd 8, Drawingo.f lesion,which is'to be sent . 'with data sheet.

,FIG.. 21-12-cont’d 8, Drawingo.f lesion,which is’to be sent
. ‘with data sheet.

and behaves clinically as if it were malignant, the dentist should search for further information. ~ negative pathol- .ogy report for cancer should not lull the dentist into a false sense ‘of security when the clinical charact~ristics of  the lesion still indicate malignant potential. If the pathol- , oS}’ report dOes not corroborate the clinical impression of the
l sion, the biopsy’ procedure should’ be. repeated. The area
bopsied may have been nondiagnostic or nonrepresentative of the.entire lesion, or the pathologist may have been. unfamiliar with the appearance of oral lesions. Clinicians, should always keep in mind that a ‘pathologist’s report can be in error. General pathologists unfamiliar,with oral
tissues mayread several types ‘of benign oral pathologic conditions as malignant, which is why many head and neck surgeons repeat the biopsy procedure of oral lesions before.performing ablative surgery. The second specimen is sent to a,pathologist who. has expertise.in oral pathology.
It is important that the dentist completely understand the terminology in the pathology report. If unsure or unfamiliar with .any terminology, the dentist should . contactthe pathologist to discuss the findings traught with the bad news and thrown into a state ofdepression. Thus each dentist must carefully handle theseinstances in his or her own way and never forget t9 keepthe patient’s best interests in mind.

 

 

 

 

 

 

 

PRINCIPILES OF BIOPSY

PRINCIPILES OF BIOPSY

Biopsy is the removal of tissue from a .ltvlng individual for diagnostic. exammanon. It is the least equivocal (most : diagnostic) of all the diagnostic procedures performed in the Iaboratory and should be carried out whenever a  _definitive diagnosis cannot be obtained using less invasive diagnostic modalities. The four major types of biopsy in and around the oral cavity are (1) cytology, (2) aspiration biopsy, (3) Incisioaal biopsy, and (4) excisional biopsy.

Oral Cytology
Two main forms of oral cytology can be used in clinical .practlce=-dtffertng in the method of cellular collection ‘.’ and in diagnosis: .~he firstis exfoliative cytologic examination for tumor cells, which was first described as a diagnostic procedure for detection of uterine cervical malignancy. Although application to the oral cavity has been
advocated, it should be used as an adjunct to, not a substitute
for, .incisiona  or excislonal biopsy. Studies have ._shown exfoliative oral cytology to be unreliable u.c., having an-unacceptable number of.false negatives) .•..~p<,:ual- Iy when pathologists who lack expertise In oral c;yWlo.gy•· examine the specimen.

Technique of oral brush cytology. The brush, is placed in contact with oraleptthellum and rotated with firm pressure 5 to 10 times (Fig. 21-5; B). Properly perfoIllied, the brush collects cells from all three layers of the
epithelium: (1) the basal; (~) intermediate, and (3) superficial layers. The cellular, material collected on the brush is transferred .to a glass slide and flooded with fixative- (Fig. 21-0, C); After the slide is dry, it is sent to a Special laboratory where the specimen is evaluated by both a
.computer system and a pathologist to first determine that ‘the biopsy brush has penetrated to the basement membrane. If the biopsy has’ 09t collected cells .from the full thickness of the epithelium, the dentist will be.informed that the sample was inadequate for analysis. The brush
cytology should then be repeated.

FIG. 21-5 Technique of oral.brush cytology, A, Brush that is used to obtain specimen. 8, Brush contacts tissue in area where cells are' desired and is rotated 5 to 10 times with moderate pressur ' C, The

FIG. 21-5 Technique of oral.brush cytology, A, Brush that is used to
obtain specimen. 8, Brush contacts tissue in area where cells are’
desired and is rotated 5 to 10 times with moderate pressur ‘ C, The

Aspiration Biopsy
Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration of its contents. Two main types of aspiration biopsy are used in clinical practice: l’he first is used only to determine whether or not a reston contains fluid or air; the second is used to remove cellular material
for diagnostic examination by a pathologist. The latter technique is usually performed by a pathologist trained in the technique of fine needle aspiration (FNA). Patients are frequently referred to pathologists for FNA when a soft tissue mass is detected below the surface of the skin or mucosa
during clinical examination. The pathologist uses a special – syringe and needle to enter the mass and collect cells for histologic examination. Neck masses can be reliably diagnosed using this technique. Because deep masses are difficult to biopsy, FNAbiopsy is a very powerful tool.

Aspiration of a lesion to determine whether or not it contains fluid is done routinely before opening into radiolucent lesions of the jaws. Inability to aspirate fluid or air indicates that the mass is probably solid. Aspiration
of a /Ieston can yield extremely valuable information about its nature. A radiolucent lesion .in- the jaw that yields straw-colored fluid on aspiration ‘is most likely a cystic lesion. If pus is aspirated, an inflammatory or infectious process should be considered (i.e., abscess). Air on
aspiration may indicate that a traumatic bone cavity has been entered. Blood on aspiration could represent several sions, themost important of which is a vascular malformation in the jaw. However, other vascular lesions may produce blood on aspiration. Aneurysmal bone
cysts, central giant cell granulomas, and other lesions can produce a bloody aspirate. A fluctuant mass in the soft tissues should .also be aspirated to determine its contents before definitive treatment. Any radiolucency in the bone of the jaws should be aspirated before surgical intervention to rule out a vascular lesion that could result in Iifethreateni g
hemorrhage if incised. Material obtained by aspiration can be submitted for pathologic examination, chemical analysis, or microbiologic culturing.

Incisional Biopsy
An incisional bIopsy .is a biopsy that samples only a particular or representative part of the lesion. If the lesion is large or has different characteristics at different locations, more than one area of the lesion may .require sampling. Indications. If the area under investigation appears
difficult to excise because of its extensive size (i.e., larger than 1 ern in diameter), hazardous location’, or whenever the clirtician suspects malignancy, incisional biopsy is indicated.

Excisional Biopsy
An excisional biopsy implies removal of the entire lesion at the time the surgical diagnostic procedure is performed. A perimeter of normal tissue surrounding the lesion is also excised to ensure total removal. The entire
lesion made available for pathologic examination, and complete excision may constitute definitive treatment. Indications. Excisional biopsy should be used with smaller lesions (less than 1 cm in diameter) that on clinical
examination appear to be benign. Any lesion that can be removed completely without mutilating the patient is best treated by excisional biopsy. Pigmented and small vascular lesions should also be removed in
their entirety. Principles. The entire lesion, along with 2 to 3 mrn of
normal-appearing surrounding tissue, is excised.

EXAMINATION AND DIAGNOSTIC METHODS

EXAMINATION AND DIAGNOSTIC METHODS

Lesions -of the oral cavity and perioral areas must be identified and characterized so that specific therapy can lead to elimination of the lesion. When a lesion is discovered, seyeral important, orderly stepsshould be undertaken to identify and characterize it (Fig, 21-1), These ‘steps include
the’ health history, history of the specific lesion,clinical examination, radiographic examination, laboratory Investigation, and, if indicated, surgical procedures to obtain a specimen for pathologic examination.

When the patient or dentist’ discovers a lesion, the dentist must be careful how this information is discussed with the patient. The words lesion, tumor growth, and biopsy carry terrifyiling connotations to many patients

FIG.21-1 Decision tree for treatment of oral lesions.

FIG.21-1 Decision tree for treatment of oral lesions.

The empathetic dentist can spare patients from anxiety and frustration by carefully wording the discussion of the lesion. It behooves the dentist to remember and make the patient aware that the vast majority of lesions discovered in the oral and maxillofacial area are benign.

Health History
The overall medical status of the patientis of paramount importance .when investigating .a lesion. An accurate health history and, if needed-a thorough clinical evaluation or ‘consultation with medical specialists are mandatory for two basic reasons: 1. The first reason is that a preexisting medical problem may affect or be affected by the dentist’s treatment of
the patien!: As outlined in Chapters 1 and 2, patients with certain medical conditions, such as congenital heart defects, coagulopathies, and hypertension, may require special precautions when any surgical treatment is required: Furthermore, surgical intervention may upset the delicate balance between health and disease in a poorly controlled diabetic or imrnunocompromised person.

Clinical Examination

When a lesion is discovered, it must be carefully examined for clues to its nature. Furthermore, a thorough examination of the areas around the lesion, including the regional lymph nodes, is mandatory. Once the examination is complete, adetailed description of the findings is placed in the patient’s chart, It is very helpful to draw the lesion in the chart or on a schematic of the oral cavity and perioral areas (Fig. 21-2). A description and illustration allow the dentist to follow the course of the lesion over time and to determine whether it is resolving or changing in nature.

The anatomic ‘locationof the mass. Lesions may arise from any tissue within the oral cavity, including epithelium, subcutaneous and submucosal connective tissue, muscle, tendon, nerve, bone, blood vessels, and salivary
glands. The dentist should ascertain as much as possible which tissues are contributing to the lesion. The exact anatomic location of the lesion should aid in this determination. For example. if a mass is present on the dorsum
of the tongue, the dentist must consider an epithelial, connective tissue, or muscle ‘Origin for the mass. Similarly, a swelling on the inner aspect of the lower lip” should prompt the dentist to include a salivary gland
etiology in the differential diagnosis. \ Vhcncver a lesion is discovered, the dentist should always try to elucidate the cause of the lesion based on its anatomic location. The role of trauma in the appearance of oral lesions
should always be entertained (and a search for a SOUTce
of trauma undertaken). Ill-fitting prosthetic devices, chronic cheek biting and other habits, sharp teeth, and so on are common causes of oral lesions. Periapical and periodontal dental pathologic conditions also cause a
high percentag e of oral lesions.

HG. 21·2 Illustrations of eril cavity and perioral areas, which are useful for indicating size and location .

FIG. 21·2 Illustrations of eril cavity and perioral areas, which are useful for indicating size and location.

FIG. 21-2-cont'd For legend see page .0461

FIG. 21-2-cont’d For legend see page .0461

BOX 21-1
Physical Types of Lesions
Bulla (pI. bu’lae): Loculated fluid in ‘or under the
epithelium of skin or mucosa; a large blister
Crusts: Dried or clotted serum protein on the surface of .
skin or mucosa
Erosion: Superficial ulcer (i.e., excoriation)
Macule: Circumscribed area of color change without
elevation
Nodule: Large palpable mass, elevated above the
epithelial surface –
Papule: Small palpable mass, elevated above the epithelial
surface .
Plaque: Hat elevated lesiori; the confluence of papules
I Pustule: Cloudy or white vesicle, the color of.which
I results from the presence of polymorphonuclear leukocytes
(i.e., pus)
Seal: Macroscopic accumulation of keratin
Ulcer: Loss of ~pi helium , .
Vesicle: Smalilocuiation of fluid in or under the epith Jm; a small blister

2. The overall physical character of the lesion. The lesion should be described in proper medical terminology, . because lay terminology is sometimes misleading, For example, a “swelling” may be interpreted in many ways. Box 21-1 lists the more common physical descriptions that are useful in describing oral pathologtc entities. A lesion’s physical characteristics should always be categorized as (at least) one of the several
types of lesions listed
3. The size and shape of the lesion. Accurate recordings of these two basic physical characteristics should be made for future reference.

4.. Single versus multiple lesions. The presence. and locitien of multiple lesions is an important diagnostic . sign. When multiple areas of ulceration are found within the mouth,.the dentist can beginto rank the differential diagnostic possibilities. It is unusual to find multiple areas of carcinoma in the mouth,  whereas a vesiculobullous disease commonly presents
with such a pattern. Similarly’, an ulcerated lesion on the lip and tip of the tongue (the so-called kissing ulcers) may indicate an infectious process
whereby one iesion in fects the tissue with which it comes into contact.
5.· The surface of the lesion. The surface may be smooth, -lobulated, or irregular, If ‘ulceration’ is present, the characteristics of the ulcer base should be recorded. Ulcer beds can be smooth; full of granulation tissue;
covered with a slough, membrane, or scab; or fungating, such as is seen with-some malignancies.

6. The colorof the lesion. The color or colors are an important consideration. A bluish swelling that blanches on
pressure m y indicate a vascular lesion, whereas a . bluish lesion that does not blanch may. indicate a mucus-containing lesion. A pigmented lesion of the oral mucosa may carry more importance than a lesion of normal ·color. An erythematous lesion may be more qminous than a white lesion. Some.lesions may have’ more than one COlor, and this should be noted in
detail. Frequently, inflammation is superimposed on areas of the lesion because of mechanical trauma or ulceration, which gives a varied plcture from one time
.to the next.
7. The sharpness of the boundaries of the lesion. If a mass
is present, is it fixed to surrounding deeper tissues or
is it freely movable? The determination of the boundaries
will aid in esrablishing whether the mass is fixed
to bone; arising from the bone and extending into
soft tissues, or of an infiltrating nature. The same
applies to an ulceration: however, a description of

FIG. 2JJ A, Anatomic lCX:lIti9l1 of cervlcotaclal lyrnph nodes

FIG. 2JJ A, Anatomic lCX:lIti9l1 of cervlcotaclal lyrnph nodes

of the margfns, The margin of an ulcer may be flat,rolled, .raised, or everted. The.,amsisteno: o(the lesion to palpation. The consistency of lesions is described as soft, as in the case of a
lipoma; firm, whichis the consistency of a fibroma;
or hard, as in the’ case of an osteoma or tori. Indurated
simply ‘means firm or hard.
9. Presence of ttuctuation. Fluctuation is the term given to
a wavelike motion felt onpalpatmg a mass or cavity
with nonrigid walls, which contains fluid. This is a
valuable physical sign,’ because it- usually indicatesfluid
within the mass. It ,can be e~y palpating
with two.or more fingers in a’rhythmic fashfon, such .
tha t- as one ‘finger. exerts pressure, the othe-r finger
feels the impulse transmitted through the fluid-filled
cavity.
10: Presence of pulsation. Palpation of a mass may reveal. a
pulsatile quality, which indicates a large vascular component. This IS especially important in ~ny lesions. A
thrill is the name given ‘tb the palpable vibration
accompanying a vascular murmur or. pulsation. If a
thrill is palpable, auscultation with a stethoscope may
reveal a briiit,or audible murmur: Lesions with palpa- ble f~riiIs or audible bruits should’ bereferred to a specilis( tor’ treatment, because life-threatenlng.hemor-
rhage can .artse when biopsy is attempted.
Continued.
11. Lymph node examination. No evaluation of an oral
lesion Is complete without a thorough regional lymph
node examination. Before any biopsy procedure, it is
particularly important to perform a thorough examination
of the regional lymph nodes. Sometimes lymphadenitis
develops in regional nodes after a biopsy
procedure. The enlargement of these nodes as a result
of inflammation may pose a problem in differentiat-
, Inglnfectlon or inflammation from metastatic spread
of tumor. Fig:2I’~3 illustrates the important and more
common lymph nodes in the maxillofacial region. ‘
‘When recording findingsthe fo!Iowing five characteristics
should routinely be included: (1) location; (2) size, -e :»
preferably giving the diameter in centimeters; (3) tenderness
(painful versus nonpainful); (4.) degree of fixation
(movable,’ matted, or fixed); and (5) texture (soft, hard, or
firm). ‘Normal- lymph nodes are not palpable. However,
nodes enlarge with inflammation and may be palpable as
.a result. Cervical nodes up to 1 cm in diameter are almost
always felt in the cervical region of children up to age 12
and are not an abnormal finding. The standard examination
of the: lymph nodes requires only simple inspectlon
and palpation. It is always useful to compare sides by using
the middle three fingers for palpation. This examination is
methodic and proceeds downward asJollows: (1) occipital
and postauricular; (2) submandibular and submental; (3)
” anterior cervical triangle (i.e., upper end of deep cervical

 FIG 21-3

FIG 21-3

fLG. 21-4 A, Radioqraphic appearance of cyst (arrows). :\ute penpheral condensmg osteitis around radiolucent center. B, Radiographic appearance of bone destruction by malignancy (arrows). Sq~amous cell carcinoma has eroded into mandible. Note ragged appearance

fLG. 21-4 A, Radioqraphic appearance of cyst (arrows). :\ute penpheral condensmg osteitis around radiolucent center. B, Radiographic appearance of bone destruction by malignancy (arrows). Sq~amous cell carcinoma has eroded into mandible. Note ragged appearance

chain); J..f) downward along sternocleidomastoid muscle (i.e., superficial cervical nodes); 15) posterior triangle t i.e., lower end of deep cervical chain); and (6) supraclavicular. Movements during palpation should be slow and gentle:  the fingers move across each arc.i examined in vertical and horizontal directions followed by rotary motion.

Radiographic Examination
Radiographs are useful as diagnostic adjuncts 1.0 the clinical examination and history of lesions within or adjacent to bone. When lesions within the sort tivsues arc proximal to ‘bone, radiographs .may elucidate whether the lesion is  causi ng an osseous reaction or erodillg into the bone. ,\
\ ;!fIN\’ of radiographic projections may-he used, depending 01 ::,~, anatomic location of the lesion. Most pathologic UlIlLI,tJ(‘ll\ 01 the mandible or maxilla can be satisfactorily dvmonvtrated by routine radiog.raplly, but, occasionally,  . pccial imaging techniques are required to elucidate some particular facet of the case under investigation.

BOX 21-2
Indications for Biopsy
~ Any .lesion that persists for more than 2 weeks with
no apparent cause . .
•. Any inflammatory lesiofl that does not respond to-
. local treatment after 10 to 14 days (after removing
local irritant)
• Persistent hyperkeratotic changes in surface tissues .
• Any persistent tumescence, either vi~ or palpable
beneath relatively normal tissue. .
• Inflammatory changes of unknown cause that “persist
for long periods :,.
• Lesions that interfere with local function (e.g;, fibfoma)
• Bone lesions not specifiCilllyidentified by clinical and
. radiographic findings .
• Any lesion that has the characteristics of malignanCy.
BOX 21-3

Characteristics of Lesions that Raise Suspicion of Malignancy
Erythroplasia: Lesion is totally red or has a speckled red
an(! .white’ appearance
Ulceration: Lesion is ulcerated or presents as.an ulcer:
Duration: Lesion has persisted more than 2 weeks
Growth rate: Lesion exhibits rapid growth
Bleedlhg: lesion bleeds on gentle manipulation
Induration: Lesion and surrounding tissue is firm to the
touch
FiXation: lesion feels attached to adjacent structures

extent of the cyst. Radiopaque probes (i.e., needles) can be used to localize a foreign object ‘or pathoiog.ic· entity.

Laboratory Investigation
Several oral lesions may be manifestations of systemic diseases. For instance, multiple lytic lesions and loss of lamina dura bone suggest the possibility .of hyperparathyroidism. Serum levels of calcium, phosphorus, and alkaline phosphatase should identify this metabolic abn ormality. A patient with multiple radiolucencies of the jaws or other bones may also have multiple myeloma.  Serum protein analysis can be useful for identifying this drsease process.

Surgical Specimen for Pathologic Examination
Once the ‘preceding s~ps have been accomplished, the ‘dentist should compilea differential diagnosis. In most instances the data obtained from the history and the clinical and radiographic examinations provide enough
information for a tentative diagnosis. Lesions that appear traumatic in origin may. be initially’ treated nonsurgically by elimination of any continued source of irritation (e.g., relieve or’ reline dentures, smooth a ‘sharp tooth or appliance).  Observation For 10 to 14 days will verify the presumptive diagnosis in these cases; that is, the lesion should heallf trauma is a cause.

 

Principles of Differential Diagnosis and Biopsy

CHAPTER OUTLINE

EXAMINATlON AND DIAGNOSTIC METHODS
Health History
History of the Specific Lesion
Clinical Examination, • ‘
Radiographic Examination
Laboratory Investigation
Surgical Specimen for Pathologic Examination
PRINCIPLES OF BIOPSY
Oral Cytology
Technique of Oral Bru~~ Cytology
. Indications, , .
Aspiration Biopsy
, Indications
Technique
Incisional Biopsy
Indications
Principles
Excisional Biopsy
Indications
Principles
S0FT TISSUE BIOPSY’ TECHNIQUE AND SURGICAL
PRINCIPLES
Anesthesia
tissue Stabilization
Hemostasis
…Jncision
Handring of Tissue
Identification of Surgical Margins
Specimen Care
Surgical Closure
Biopsy Data Sheet
INTRAOSSEOUS, OR HARD TISSUE, BIOPSY TECHNIQUE
AND SURGICAL PRINCIPLES
Aspiration Biopsy of Radiolucent Lesions
Mucoperiosteal Flaps
Osseous Window
Removal of Specimen
Specimen Care-
REFERRALS FOR BIOPSY
He.alth of Patient
Surgical Difficulty
Potential for Malignancy

 

Management of Oral Pathologic Lesions

Management of Oral Pathologic Lesions

r:dentist irt general practice has a more thorough and continuous exposure to his or her patients’ oral cavities and perioral areas than any other health care provider. Therefore the dentist is responsible for maintaining the overall health and well being of these structures. WhetHer directly involved in the surgical management of pathol  gic entities or indirectly involved through referral to another health care provider; the dentist is  the individual who provides the needed continuityof care to help ensure adequate patient follow-up and dental reconstructive efforts.
The unique role of general dentists as oral health experts requires them to.
be constantly on the lookout for pathologic lesions during the everyday care of patients. General dentists must be aware of the natural history of the more ‘common maxillofacial disease processes and must-be astute diagnosticians. As with any disease process in dentistry and medicine, prevention is the best form of therapy, and early diagnosis and treatment is the best way of managing pathologic entities.
The next two chapters describe the role that the general dentist-should
assume in the management of a patient’s pathologic conditions. The most
important aspect of this care begins with a thorough patient examination and an accurate diagnosis of disease. Chapter 21 covers these topics in detail and in a fashion meaningful to the general dentist, Chapter 22 describes the surgical management of pathologic diseases of the oral cavity and contiguous structures. Details of surgical technique are provided in depth for lesions that the general dentist may encounter. The surgical management of major pathologic conditions aed tumors of the oral and maxillofacial region is also presented, but the emphasis is on the general dentist’s role in overall ‘patientmanagement.