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  • SJM Dental college and hospital Chitradurga
  • Srinivas institute of dental sciences, mangalore
Britto et al. World Journal of Pharmaceutical and Life Sciences
Dr. Varsha R. Shetty. J. and Dr. Frankantony P. Britto*
1Asst. Professor, Department of Oral and Maxillofacial Pathology, Shrinivas Institute of Dental Sciences, surathkal,
2Asst. Professor, Department of Oral and Maxillofacial Pathology, SJM Dental College and Hospital, Chitradurga.
Article Received on 06/10/2017 Article Revised on 27/10/2017 Article Accepted on 17/11/2017
Biopsy, a Greek-derived word (bio-life; opsia-to see)
loosely translated as “view of the living,” is defined as
removal of tissue from the living organisms for the
purpose of microscopic examination and diagnosis. The
term “Biopsy” was introduced into medical terminology
in 1879 by Ernest Besnier.[1] Biopsy is often the
definitive procedure that provides tissue for microscopic
analysis when additional information is required to guide
any indicated therapy.[2] The dental clinician should be
aware of the various biopsy techniques that are available
for the oral tissues, as well as the challenges specific to
these tissues.
The main objective of biopsy is for confirmation of
clinical and radiographic diagnosis, surgical management
and to determine the complete removal of a lesion.[3] It is
also valuable in determining the type of the treatment to
be instituted in certain diseases. Biopsy reports are also
used as medicolegal records if need arises.[4]
Biopsy is essential if there is any clinical suspicion of
malignancy, such as an enlarging mass, chronic
ulceration, tissue friability, induration on palpation or
persistence of mucosal changes for more than 2 weeks
despite removal of local irritants and shows no response
to treatment.[3,4,5] Any tissue surgically excised, Any
tissue spontaneously expelled from a body orifice,
Material from a persistent draining sinus whose source
cannot be readily identified.[4] A biopsy is also used as
complement in the diagnosis of certain disorders of
infectious origin, such as lesions of syphilis or
tuberculosis. Another indication for biopsy is
confirmation of the diagnosis of certain vesiculobullous
Bony lesions accompanied by pain, paresthesia or other
symptoms, rapid expansion as evidenced by successive
radiological evaluations. Lesions with rapid bone loss,
irregular widening of the periodontal ligament, spiking
root resorption and tooth mobility in the absence of
trauma or an identifiable source of inflammation are also
indicated for biopsy.[3]
Biopsy is contraindicated when the general health
condition of the patient is very poor, presence of acute,
virulent, pyogenic infection, vascular lesions where
significant hemorrhage may be encountered and caution
should therefore be exercised in the biopsy of any lesion
with red, purple or blue coloration or with blanching or
pulsation on palpation.[4,6]
Biopsy is not advised in the case of multiple
neurofibromas due to the risk of neurosarcomatous
transformation, or in tumors of the greater salivary
glands. Such biopsies must be performed by specialized
surgeons in order to avoid damaging the nearby
anatomical structures and causing the spread of tumor
cells, as this would adversely affect the prognosis.[7]
Review Article
ISSN 2454-2229
wjpls, 2017, Vol. 3, Issue 10, 37-39
World Journal of Pharmaceutical and Life Sciences
SJIF Impact Factor: 4.223
*Corresponding Author: Dr. Frankantony P. Britto
Asst. Professor, Department of Oral and Maxillofacial Pathology, SJM Dental College and Hospital, Chitradurga.
Proper management of an oral mucosal lesion begins with diagnosis, and the gold standard for diagnosing disease,
oral or otherwise, is tissue biopsy. Oral tissue biopsy may be necessary for lesions that cannot be diagnosed on the
basis of the history and clinical findings alone. Accurate diagnosis of premalignant or malignant oral lesions
depends on the quality of the biopsy, adequate clinical information and correct interpretation of the biopsy results.
This article provides an overview of the oral soft-tissue biopsy and highlights some potential pitfalls.
KEYWORDS: Biopsy, Incisional, Excisional.
Britto et al. World Journal of Pharmaceutical and Life Sciences
Site of Biopsy
The biopsy site must be selected carefully to ensure that
it yields accurate results. In case of large
ulceroproliferative lesion there may be some areas which
demonstrate obvious invasive disease, while others may
indicate epithelial dysplasia. For such lesions, multiple
specimens must be taken. Using toluidine blue or direct
fluorescence visualization can help a clinician highlight
the most severe or significant change for biopsy.[8]
Excisional biopsy is usually advised for the smaller
lesions.[3,4] Areas near to teeth, bone or cartilage should
be avoided if possible because this is where tumor
invasion is less and are frequently sites of necrosis.[3]
Types of biopsy
Incisional biopsy: Incisional biopsy provides a
representative sample of tissue for diagnostic purposes. It
is the method of choice when the differential diagnosis
includes malignancy. Its accuracy is relative, since by
nature it does not allow study of the entire lesion. The
technique used for incisional biopsy is usually
straightforward, An elliptical incision, with a length-to-
width ratio of 3:1, is made with a size 15 scalpel blade.
The elliptical shape facilitates primary-intention closure.
The inferior incision is made first, so that hemorrhage
does not obscure the surgical field. The anterior tip of the
ellipse is gently lifted with tissue forceps, and the base is
Excisional biopsy: is the complete removal of a lesion
for functional and aesthetic purposes, as well as to
confirm the clinical diagnosis. This is appropriate only if
the lesion is almost certainly benign. The size,
accessibility and regional anatomy of the lesion must all
be considered. Small, pedunculated, exophytic lesions in
accessible areas are excellent candidates for excisional
biopsy. An ellipse is traced around the lesion, with the
blade angled toward the centre of the lesion. This
produces a wedge-shaped specimen that is deepest under
the centre of the lesion and leaves a wound that is simple
to close.[5,9]
Punch Biopsy: Is used for either incisional biopsy or
excision of a small lesion at an accessible site. The
lateral tongue and buccal mucosa are appropriate sites
for punch biopsy, as it must be feasible for the device to
approach the mucosal surface perpendicularly. The
punch is placed on the lesional tissue, and a downward,
twisting motion is applied. The tissue core is then
severed at the base with curved scissors.[5]
Punch biopsy is not appropriate for vesiculobullous
diseases, as the twisting action would detach the
epithelium and prevent proper assessment of the
interface between epithelium and connective tissue that
is necessary for subclassification of such lesions.[5]
Electrosurgery and Laser Techniques: These
techniques produce thermal artifacts that may hamper
histologic interpretation; accordingly, these methods
should be used with caution for diagnostic biopsy or
when information from the margins is required. A laser
produces a zone of thermal coagulation smaller than that
of electrosurgery, but still, a 0.5-mm margin should be
maintained between the cut and the representative area to
be sampled.[5]
Brush biopsy: Brush biopsy has been advocated as a
screening modality for lesions that may otherwise not be
sampled. A stiff brush is used to collect cells from all
epithelial layers through application of firm pressure
with a rotational movement. Pinpoint bleeding indicates
sufficient depth of cell collection. The sample is then
transferred to a glass slide and sent to the laboratory for
analysis. If atypical cells are found, conventional biopsy
is also required.[5]
Biopsy procedure
Obtaining adequate and appropriate tissue sample is very
important for the diagnosis purpose. An ideal mucosal
biopsy should be of sufficient depth to include the entire
layer of epithelium and a portion of the underlying
connective tissue.[3,4] Biopsies of the mucosa should be at
least 3 mm in diameter. Since biopsies shrink after
formalin fixation, punch biopsies 4 or 5 mm in diameter
are recommended to ensure an adequate sample size. The
depth should be at least 2 mm.[8]
Points to remember while taking a biopsy[4,9]
1. Use of antiseptic like iodine leads to the
pigmentation of the section leading to faulty
2. While injecting the local anesthesia, one should be
careful not to inject the solution into the lesion or
close to it. Whenever possible it would be better to
give block injections instead of infiltrations
3. The tissue should be handled with minimal force as
the specimen may get distorted and become useless
in formulating an accurate diagnosis.
4. As far as possible using the forceps on the surface of
the biopsy should be avoided. When the teeth of
these instruments penetrate the specimen, it results
in voids or tears and compression of the surrounding
5. Sutures can be placed which will help in handling
the tissue as well as to give tension for the tissue, to
ease the surgery.
6. It is observed that the heat from electrocautery
produces marked alteration in both the epithelium
and the connective tissue. Those lesions where the
margins should be examined, electrocautery are
contraindicated. The combination of electrocautery
and a scalpel should be considered.
Fixation and Transport
Ensure the specimen is placed in an adequate volume of
fixative, this should be at least ten times the volume of
the specimen. Avoid the use of gauze to place the
specimen onto as it merely absorbs the fixative and can
make separation of the specimen from the gauze
Britto et al. World Journal of Pharmaceutical and Life Sciences
difficult.[9] The fixative should be selected depending on
the purpose and method of tissue processing. For routine
histological reporting, 10% neutral buffered formalin is
used. The tissues for frozen sections can be transported
either in liquid nitrogen flasks or in Michel’s solution.[10]
Correct labeling should be done immediately. The
fixative bottle should be properly sealed and sent to the
histopathology laboratory. A detailed clinical data,
photographs of the lesion, radiographs, reports of other
laboratory investigations if available also should be
submitted along with the biopsy specimen.[4,5,9]
Accurate diagnosis by the oral pathologist depends on
the proper biopsy techniques followed by the dental
surgeon, so that it can be beneficial to the patient’s
health. Thus every dental surgeon should have good
knowledge of the oral biopsy indications and the surgical
techniques and thus can render invaluable service to his
patients with early detection and diagnosis of the disease.
1. Zerbino DD. Biopsy: Its history, current and future
outlook. Lik Sprava, 1994; 3-4: 1-9.
2. Patton LL, Epstein JB, Kerr AR. Adjunctive
techniques for oral cancer examination and lesion
diagnosis: a systematic review of the literature. J
Am Dent Assoc, 2008 July; 139(7): 896-905.
3. Sanjay Kar, Prasant MC, Kedar Saraf, Kishor Patil.
Oral biopsy: Techniques and their importance.
American Journal of Advances in Medical Science,
2014; 2(3): 42-46.
4. Karkera BV, Shivakumar BN, Mohammed A, Vidya
M, Nandaprasad S, Hemanth M. Biopsy: Clinical
implications. J Dent Oral Hygiene, 2011; 3(8):
5. Sylvie-Louise Avon, Hagen B.E. Klieb. Oral Soft-
Tissue Biopsy: An Overview: J Can Dent Assoc,
2012; 78: c75.
6. Mota-Ramirez A, Silvestre FJ, Simo JM. Oral
biopsy in dental practice. Med Oral Patol Oral Cir
Bucal, 2007; 12: 7: 504-510.
7. Kumaraswamy KL, Vidhya M, Rao PK, Mukunda
A. Oral biopsy: Oral pathologist’s perspective. J Can
Res Ther, 2012; 8: 192-8.
8. Catherine FP, Samson NG, Kenneth WB, Michele
WP, Miriam PR, Lewei Z: Biopsy and
Histopathologic Diagnosis of Oral Premalignant and
Malignant Lesions: JCDA, April 2008; 74: 3.
9. Oliver RJ, Sloan P, Pemberton MN. Oral biopsies:
methods and applications. Brit Dent J., 2004;
196(6): 329-33.
10. Bancroft JD, Gamble M: Theory and Practice of
histological techniques, 6th edition: Fixation of
tissues: chapter, 4: 53-74.
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Biopsies are an important diagnostic tool for the diagnosis of lesions ranging from simple periapical lesions to malignancies. Planning prior to performing a biopsy is essential. It will be beneficial to the receiving pathologist in reaching a helpful and meaningful diagnosis, and therefore ultimately and more importantly, to the patient. This paper presents an updated view of biopsies and discusses some of the potential problems with biopsy technique and specimens and how to overcome them.
Full-text available
Many oral lesions may need to be diagnosed by removing a sample of tissue from the oral cavity. Biopsy is widely used in the medical field, but the practice is not quite widespread in dental practice. As oral pathologists, we have found many artifacts in the tissue specimen because of poor biopsy technique or handling, which has led to diagnostic pitfalls and misery to both the patient and the clinician. This article aims at alerting the clinicians about the clinical faults arising preoperatively, intraoperatively and postoperatively while dealing with oral biopsy that may affect the histological assessment of the tissue and, therefore, the diagnosis. It also reviews the different techniques, precautions and special considerations necessary for specific lesions.
Full-text available
The conclusions drawn from the study of an oral biopsy are considered essential for the definitive diagnosis of diseases of the oral mucosa, and for the subsequent planning of appropriate treatment. Although the obtainment of biopsies is widely used in all medical fields, the practice is not so widespread in dental practice--fundamentally because of a lack of awareness of the procedure among dental professionals. In this context, it must be taken into account that the early diagnosis of invasive oral malignancy may be critical for improving the patient prognosis. However, in some cases the results are adversely affected by incorrect manipulation of the biopsy material. The present study provides an update on the different biopsy sampling techniques and their application. Such familiarization in turn will contribute to knowledge of the material and instruments required for correct biopsy performance in dentistry, as well as of the material required for correct sample storage and transport.
Full-text available
Accurate diagnosis of premalignant or malignant oral lesions depends on the quality of the biopsy, adequate clinical information and correct interpretation of the biopsy results. The purpose of this paper is to review the procedures for obtaining appropriate biopsy samples, and the criteria for diagnosing and grading dysplasias. The World Health Organization's description of the architectural and cytologic epithelial changes that characterize dysplasia is detailed, and guidelines for following up patients with premalignant and malignant lesions are provided. The benefits of using the centralized services and expertise of the British Columbia Oral Biopsy Service are also reviewed.
The term "biopsy" was introduced into medical terminology in 1879 by Ernest Besnier. The first diagnostic biopsy in Russia was performed in 1875 by M. M. Rudnev. It is possible to make out three stages in more than 100 year history of the method development: an occasional use of histologic procedure involving living organs and tissues accessible for observation and study (approximately until the late 19th century); restricted application of biopsy (until the mid-20th century); present stage at which the method is widely adopted and its use is general and total (with respect to human organism) not only in oncology but practically in all clinical specialties. Kinds of biopsy, excisional and incisional, are discussed as are problems of hazardousness that arise in excising body tissue for analysis in a biopsy, difficulties the pathoanatomist is faced with in interpreting histopathological preparations, reasons for faulty interpretation or failure to account for the findings, sources of error, future developments and applications. Techniques designed for getting biopsies from the heart and lungs are described, along with their diagnostic potentialities.
Adjunctive techniques that may facilitate the early detection of oral premalignant and malignant lesions (OPML) have emerged in the past decades. The authors undertook a systematic review of the English-language literature to evaluate the effectiveness of toluidine blue (TB), ViziLite Plus with TBlue (Zila Pharmaceuticals, Phoenix), ViziLite (Zila Pharmaceuticals), Microlux DL (AdDent, Danbury, Conn.), Orascoptic DK (Orascoptic, a Kerr Company, Middleton, Wis.), VELscope (LED Dental, White Rock, British Columbia, Canada) and OralCDx (Oral CDx Laboratories, Suffern, N.Y.) brush biopsy. They abstracted data relating to study design, sampling and characteristics of the study group, interventions, reported outcomes and diagnostic accuracy of adjunctive aids from 23 articles meeting inclusion and exclusion criteria, including availability of histologic outcomes. The largest evidence base was for TB. A limited number of studies was available for ViziLite, ViziLite Plus with TBlue and OralCDx. Studies of VELscope have been conducted primarily to assess the margins of lesions in known OPML. The authors identified no studies of Microlux DL or Orascoptic DK. Study designs had various limitations in applicability to the general practice setting, including use of higher-risk populations and expert examiners. There is evidence that TB is effective as a diagnostic adjunct for use in high-risk populations and suspicious mucosal lesions. OralCDx is useful in assessment of dysplastic changes in clinically suspicious lesions; however, there are insufficient data meeting the inclusion criteria to assess usefulness in innocuous mucosal lesions. Overall, there is insufficient evidence to support or refute the use of visually based examination adjuncts. Practical Implications. Given the lack of data on the effectiveness of adjunctive cancer detection techniques in general dental practice settings, clinicians must rely on a thorough oral mucosal examination supported by specialty referral and/or tissue biopsy for OPML diagnosis.
Oral biopsy: Techniques and their importance
  • Sanjay Kar
  • M C Prasant
  • Kedar Saraf
  • Kishor Patil
Sanjay Kar, Prasant MC, Kedar Saraf, Kishor Patil. Oral biopsy: Techniques and their importance. American Journal of Advances in Medical Science, 2014; 2(3): 42-46.
Biopsy: Clinical implications
  • B V Karkera
  • B N Shivakumar
  • A Mohammed
  • M Vidya
  • S Nandaprasad
  • M Hemanth
Karkera BV, Shivakumar BN, Mohammed A, Vidya M, Nandaprasad S, Hemanth M. Biopsy: Clinical implications. J Dent Oral Hygiene, 2011; 3(8): 106-108.
  • Sylvie-Louise Avon
  • B E Hagen
  • Klieb
Sylvie-Louise Avon, Hagen B.E. Klieb. Oral Soft-Tissue Biopsy: An Overview: J Can Dent Assoc, 2012; 78: c75.