BIOPSY AND CYTOLOGY

Biopsy
• Definition
• Biopsy is the removal of a sample of living tissue for laboratory examination.

• Rationale
• It is a dentist’s obligation to make a diagnosis, or see that a diagnosis is made, of any
pathological lesion in the mouth.
• Some lesions can be diagnosed clinically, and biopsy is not required e.g. recurrent
aphthous ulceration, Herpes simplex lesions.
• Many lesions cannot be positively diagnosed clinically and should be biopsied – or in
some cases smeared for cytopathologic examination.
• Pitfalls of relying on a strictly clinical diagnosis are numerous:
• A loose tooth may be due to a malignancy, not to advance periodontal disease.
• What appears to be a dentigerous cyst clinically e.g. may be an odontogenic
tumor.
• Harmless looking white patches may be malignant or premalignant. Red patches
are even more important.
• It has been said that “any tissue which has been removed surgically is worth
examining microscopically”
• Yet dentists in general do not follow this rule.
• However, there are some tissues e.g. gingivectomies, where every specimen need
not be submitted.
• While cancer is one disease in which biopsy is important, there are many other
lesions in which this procedure is useful.
• It is a sensitive diagnostic tool.

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• Methods of Biopsy
• Excisional – entire lesion is removed, along with a margin of normal tissue.
• Incisional – representative portion of the lesion is removed, along with a margin of
normal tissue.
• Electrocautery – tends to damage tissue and make interpretation difficult.
• Punch
• Needle and aspiration
• Curettage – intraosseous
• Exfoliative cytology.

• The Oral Biopsy – Avoidable Pitfalls.

• Tissue alteration before the biopsy is taken.
• Do not apply antiseptics e.g. iodine, or topical anesthetics to the surface of the
lesion. This may leave an unnecessary deposit on the tissues.
• Local anesthetic infiltrations should be injected around the periphery of the
lesion – infiltration directly into the lesion will cause volumetric distortion.

• Tissue alteration during the biopsy procedure.

• Impaction of bone dust, dentine dust and enamel fragments into some intrabony
lesions is unavoidable.

• Electrosurgery.
• Produces significant coagulation damage, particularly at margins of biopsy
specimen, and can completely ruin small biopsies.
• Can be useful to control bleeding.

• Crush, puncture and tear artifacts.

• Avoid grasping tissue with forceps, hemostats – these produce crush and tear
artefacts which make histologic interpretation difficult. Toothed forceps can
leave puncture holes which resemble cysts.

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 • Insert a suture through the normal tissue which is to be included in the biopsy
specimen, and apply gentle traction to the suture threads.

• Unwanted additions.
• Occasionally unwanted tissues are inadvertently included rendering histologic
interpretation difficult.
• These include fragments of calculus or plaque, which may mimic
Actinomycotic infection, starch granules from gloves, restorative and
endodontic filling materials.

• The Wrong Tissue.

• The biopsy must include all or part of the lesion, and a border of normal tissue.
• Biopsies of epithelium only are non-diagnostic because the nature of associated
connective tissue change cannot be assessed histologically.
• A negative biopsy – one that does not comply with the clinical appearance or
the history of the lesion – is not final; it simply means that the disorder in
question was not found in the sections examined by the pathologist.

• Insufficient Tissue.
• Biopsies should be no less than 2-3 mm in dimension.
• Small biopsies are difficult to orient correctly and easy to lose in handling.
• Shrinkage due to fixation and processing further reduces the size and
usefulness of a tiny biopsy.
• Balance: adequate tissue versus small as possible in the best interest of the patient.

• Tissue alterations after the biopsy is taken.

• Lack of fixative.
• Biopsy specimens should be immediately place in fixative solution, such as
10% buffered formalin in the biopsy kit.

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 • Volume of fixative should be at least 10 times the volume of tissue.
• If no formalin available, use 70% ethanol.
• If no ethanol available, use gin, vodka, rum or other spirit alcohol in a 20:1
volume proportion.
• Isopropyl alcohol (rubbing alcohol) or methyl alcohol (wood alcohol) should
not be used.
• Water and saline are unsuitable transport media.
• Formalin and water in biopsy kit vial may evaporate, leaving a white powder
which is the buffer. Adding water will therefore not help, and the tissue will
not fix. Autolysis will occur, creating artifacts of non-fixation in the
histological appearance.

• Freezing.
• Tissue specimens mailed in winter are at risk of being frozwn in transport
producing significant freeze artifact which may make histologic diagnosis
difficult.
• 10% formalin freezes at -11°C, forming ice crystals which distorts the tissue
architecture.
• To reduce the risk, the following steps can be taken:
• Do not put the biopsy in an outside mailbox overnight – drop it in an inside
mailbox in the post office building.
• Add ethanol to the formalin to lower the freezing point of the fixative solution –
ethanol, and spirits such as vodka, gin etc. in equal volume to the formalin will
lower the freezing point and reduce the risk of freeze artifact.

• The Dentists Responsibility.

• To ensure that a biopsy is taken when necessary, to submit tissue removed surgically
for examination. This involves judgment, but it is a legal responsibility.

• The obtaining of the tissue:

• To obtain a representative piece of tissue.
• Not too small.

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 • In as good condition as possible.
• Use a sharp blade.
• Do not rip or crush tissue with forceps.
• Do not inject directly into the lesion – may distort it.
• Do not paint the lesion with iodine.
• Avoid electrocautery.
• Avoid freezing.
• Fix immediately in 10% formalin
• Place the tissue on a small piece of paper to avoid its curling.
• Provide pathologist with history:
• Supply pertinent information.
• Too much history is far better than too little.
• Name, age, sex, occupation.
• Clinical appearance and location of lesion.
• History of lesion.
• Pertinent medical history.
• Clinical impression or comments.
• Radiographs – send them (or copy) to pathologist (preferable) or provide good
description.
• Photographs if possible.

• Most dentists are capable of taking biopsies but are reluctant to do so. If a dentist
feels that he/she is not qualified to perform this procedure, he/she should refer the
patient promptly to an oral surgeon or someone else who is qualified.

• The Pathologists Responsibility:

• Examine the tissue grossly.
• Decide the location from which sections should be cut.
• Examine and report on these sections.
• The report:
• Gross description.

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 • Microscopic description.
• Diagnosis.

• Interpretation of the report.

• Read it all – it can be a learning process.
• Pathologists are not infallible – it is an interpretive science.
• A negative biopsy – one that does not comply with the clinical appearance or the
history of the lesion – is not final; it simply means that the disorder in question was
not found in the sections examined by the pathologist.
• It is in order to ask the pathologist to review the sections if the clinical impression
does not agree with the pathologists report.
• Sometimes it may be necessary to do a repeat biopsy.

• Dangers of biopsy.
• Causing metastasis.
• While this is possible, the value of reaching a definitive diagnosis completely
outweighs the objection.
• Excision is better than incision.
• Do not treat tissues roughly.
• Do not biopsy a lesion which you are sure is cancer – send it to the cancer surgeon
or cancer clinic.
• Hemangioma can be dangerous – send to oral surgeon.

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 Cytology
• Both normal and malignant epithelial surfaces continually desquamate superficial cells.
• These can be demonstrated on special stains.
• This is exfoliative cytology.

• Technique:
• Scrape area with spatula or tongue depressor, or brush.
• Smear cells on glass slide, and fix immediately with 95% ethyl alcohol or spray
fixative.
• Two slides are preferred for each lesion.
• Provide clinical history.

• Interpretation
• Slides are examined by pathologist.
• Normal:
• Smears from oral mucous membranes consist almost exclusively of
• Superficial cornified squames – pink or yellow.
• non-cornified squames – green.
• Infection and inflammation:
• Leukocytes.
• Distorted or degenerating cells.
• Increased nuclear size.
• Malignant cells:
• Mainly nuclear changes.
• Enlargement of nucleus.
• Hyperchromatism.
• Thick nuclear borders.
• Clumped chromatin.
• Variation in size and shape.
• Epithelial cells tend to clump together.

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 These changes correspond to the cytological changes seen in a tissue section.
However, the emphasis in cytological examination is on cellular changes. In
biopsy, we can study tissue patterns and inter-relationships as well as cellular
changes.

• Indications:
1. General.
• Tumors and thick white lesions should be biopsied and not smeared.
• Ulcers and erythroplakias can be smeared more readily. It is easier to get to the
deep cells which are the ones required.
• In dental practice, the prime application should be for innocuous appearing lesions
for which biopsy is not planned or indicated.

2. Specific indications.
• Innocuous appearing lesions for which biopsy does not seem to be indicated.
• Patient refuses biopsy.
• After radiation/chemotherapy as a follow-up procedure.
• Lesions suspected of being viral conditions:
• Herpes simplex.
• Herpes zoster.
• Pemphigus.
• Sex chromatin studies.
• Candidiasis.

• Contraindications:
1. Do not smear a lesion suspected of being cancer – biopsy it.
2. Do not smear any tumor.

Do not attempt to smear any but the thinnest of white lesions.

• Disadvantages:
• Not as reliable as biopsy.

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 • A negative cytology report does not preclude the presence of a neoplasm. If the
lesion persists, a biopsy should be performed.
• False positives and false negatives are a problem.
• Although it is quick to perform, it requires a painstaking thorough examination by
the pathologist.

• N.B. Cytology is not, and was never meant to be, a substitute for biopsy.

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