Biopsy and medical management of oral pathoses

lectures given 10/27/2026

biopsy

removal of tissue from a living body for microscopic diagnostic examination

primary purpose- determine diagnosis to facilitate treatment

rule out malignancy / pre malignant lesions

most oral lesions are benign

what are the indications for biopsy?

any pathological condition that cannot be diagnosed clinically

lesions with no identifiable cause that persists for more than 10-14 days despite local therapy

intra bony lesions that appear to be enlarging

visible / palpable submucosal swelling

lesions with pre-malignant / malignant characteristics

lesions that have grown rapidly

red, white lesions or pigmented lesions where cause is unknown

lesion that is firmly attached or fixed to surrounding structures

ulceration

induration (lesion and surrounding tissue are firm to touch)

associated with lymph node enlargement (infections, TB)

clinical exam and work up to establish differential diagnosis

health history- lesion under investigation may be manifestation of systemic disease (leukemia, crohn’s disease)

medications- any medications that may cause oral manifestations

history of smoking- pack years

history of lesion

duration of lesion- lesion present for several years might be congenital and is more likely to be benign

change in size- clinical/radiographic, rapidly developing lesion is more ominous

change in character- lump becoming an ulcer? / vesicle that turned into ulcer

symptoms associated with lesion

pain- associated with inflammatory / infectious lesions

sensory nerve changes- parasthesia is seen with malignant / inflammatory lesions

swelling- could suggest a cyst / tumor, bony expansion could suggest a chronic process or a fibro osseous lesion

anatomic location involved

keratinized vs non keratinized

unilateral vs bilateral

salivary gland tumor will occur in an area with salivary gland

some lesions have predilection for certain areas or oral cavity

associated systemic signs / symptoms

weight loss- commonly associated with malignant lesions

neck nodes often get enlarged in pts with oral malignancies

fever and malaise are associated with infectious process

viral lesions like HIV may have oral manifestations

some immune mediated diseases manifest in oral cavity in addition to skin lesions

any historical event associated with the onset of lesions

history of trauma / cheek biting in case of ulcers

application of medications not recommended for intra oral use

history of trauma in past- leading to pulp necrosis and manifesting as radicular cyst

clinically examining and documenting the findings

examination includes inspection and palpation

anatomic locations and what type of tissues make up the area? ie lower lip and abundance of minor salivary glands

physical characteristics- ulcer / nodule / soft (lipoma) / firm (neoplasm) / fluctuant (cystic due to fluid) / hard (bony lesions and osseous growth)

single vs multiple lesions, unilateral vs bilateral

raised vs flat, exophytic vs endophytic, sessile (broad based) vs pedunculate

colored lesions that blanch on pressure and fill back up when pressure is released- likely to be vascular

vascular lesions may be pulsatile- invasive procedures such as biopsy are to be avoided in these lesions

lymph node examination

in adults, normal lymph nodes are not palpable

lymph nodes can become enlarged due to inflammation and malignant lesions

surgical procedures do induce inflammation thus causing lymphadenitis

important to establish baseline before doing biopsy- location, size, tenderness, mobile vs fixed, soft vs firm

imaging

radiographs tell us if lesion is arising from bone, eroding bone or causing bony expansion / periosteal reaction

osteomyelitis can be hard to distinguish from malignancy- what can help?

osteomyelitis is more acute and have an inciting event

malignancy is more chronic- but not too long

lab investigations

oral lesions as manifestation of systemic disease- multiple myeloma, hyperparathyroidism, lymphoma, HIV

for hyperparathyroidism- calcium , phosphorus, and alkaline phosphatase

if you decide to refer…

referral appt arranged before pt leaves office

follow up with specialist and make sure pt keeps the appointment with their office

copy of all correspondence kept on records

also the communication from specialist office, biopsy results and recommendations should all be kept

failure to diagnose and refer a pt with pathological condition is a leading cause of litigation

to biopsy or to refer…

depends on pts systemic condition, dentist’s skill and comfort level

surgical difficulty, access, risk of bleeding (vascular lesion?)

iin case of lesions thought to be malignant- perform a biopsy then refer to specialist OR refer to specialist whol will be providing the definitive treatment so that he can evaluate and does the biopsy (chance for the surgeon to see the lesion before any surgical intervention has been compromised)

if pt and dentist choose to not do a biopsy and follow up…

shared responsibility- plan for surveillance must be documented and adhered to

baseline clinical picture and imaging kept on record

making the pt aware of any alarming signs- change in size, shape, color, development of pain/discharge

what are the types of biopsies?

excisional, incisional, aspiration biopsy (radiolucencies, salivary gland swellings, rule out vascular lesions)

excisional biopsy

lesions < 1cm

definitive treatment

excision will not compromise function, risk injury to vessels or nerves

incisional biopsy

small part of lesion is removed

adequate depth- deepn and narrow specimen should be taken

can take multiple samples of characteristics of lesion differ from one site to another

armamentarium

blade

biopsy

sutures to lift, stabilize the tissue

biopsy for ulcerative lesions that are suspected to be carcinoma?

incised tissue should be included edge to ulcer base without extending into normal tissue

extending to include the normal tissue, will risk spreading the tumor

biopsy for immune based lesions

pemphigus

include perilesional tissue (normal appearing mucosa)

how do you send tissue to the lab?

send the tissue in 10% buffered formalin (pH 7), preserves cellular morphology and architecture by forming gel between aldehydes and proteins

SEND PICTURES

how do you send vesiculobullous tissue to the lab? (like pemphigus)

michel’s soultion aka michel’s transport medium

salt solution used to preserve and transport biopsy specimens for immunofluorescence studies

post biopsy

follow up in 10-14 days

next steps will depend on results- referral vs close follow up with imaging as needed

radicular cyst

most common cyst

non-vital tooth / previous trama / endodontically treated tooth

dentigerous cyst

associated with impacted tooth

odontogenic keratocyst

high risk for recurrence

aspiration will produce thick yellow cheesy material (keratin)

marsupialization of cyst

useful for very large cyst- where removal will risk jaw fracture

useful in young pts- allows teeth eruption

ideal to decompress cyst so that bone can fill in

can enucleate once cyst is smaller

only part of lining goes for biopsy- disadvantage

cyst enucleation

removal of entire cyst lining- thus the initial step is curvative, also the entire lining is given for pathological exam

ameloblastoma

true neoplasm of odontogenic epithelium

persistent, locally invasive and aggressive

treatment involves resection of the lesion and 1cm margin around the radiographic margins of the lesion

marginal mandibular resection

preserves the lower border

segmental mandibular resection

does not preserve the lower border

mandibular tori

palatal tori

cemento-osseous dysplasia

lots of options / differentials

stafne’s defect

lateral periodontal cyst

cemento-osseous dysplasia

check viability of teeth

pyogenic granuloma

dd- PCGC, POF

epulis fissuratum

apthous ulcers

herpetic ulcers?

dentigerous cysts

squamous cell carcinoma

what are reasons to consider medical therapy over surgery?

bleeding risk

aesthetic zone

high risk for post-traumatic trigeminal neuropathy

patient fear

peds pt

surgery already failed

pts unable to tolerate extensive healing process- extensive scarring, limitation in alimentation, immunosuppression

reduced procedure time

overlap conditions

pyogenic granuloma

leukoplakia/dysplasia

post-radiation fibrosis/trismus

hemangioma

pyogenic granuloma

medical therapies- topical agents (timolol, corticosteroids, imiquimod), sclerotherapy, silver nitrate

dental therapy- scaling and root planning + chlorohexidine glyconate soaks

recurrence after excision ~6% / giant (>2cm) lesions ~22%

risk factors- age (20-30s), female sex, mandibular location

leukoplakia / dysplasia

goal- prevent scc

5 therapeutic options- periodic surveillance and biopsy, excision, lesion destruction (laser, cryotherapy), topical chemotherapy (5-fluorouracil + calcipotriene), topical immunotherapy (imiquimod)

radiation therapy induced trismus

fibrosis of mucosa, skin, salivary gland, bone- hyposalivation, dysphagia, obstructive sleep apnea, edema, mucositis, pain

stretching- manual, pt, appliances, therabite, restorabite (10-14mm over 10 weeks to 12 mo)

low level laser therapy- 400-1500nm and <25 j/cm2 (5-10mm)

pentoxifylline and vitamin E- 400mg PO twice daily and vitamin E 1000 IU PO once daily for 6-24 months (10-15mm over 6 mo)

pirifenidone- 800 mg TID for 3-6 mo

hemangioma

positive on diascopy

require doppler US prior to excision- high flow v low flow

congenital hemangioma- RICH, PICH, NICH

infantile hemangioma- rapidly grows, plateaus, then involutes by school age

therapeutic options for infantile hemangioma

first-line treatement- oral propanolol 2-3mg/kg/day for at least 6 mo (95% clearance)

topical timolol- highly effective for small, superficial lesions, esp in infants younger than 8mo

intralesional pingyangmycin, corticosteroids, and vincristine are reserved for refractory pts

laser and surgery- mainly used for residual changes after involution or where medical therapy is contraindicated or ineffective

study with 853 infants treating with topical timolol, oral propanolol, intralesional pingyangmycin, or IV vincristine - there was an excellent response to therapy, esp in pts under 8 mo (89.1%)

therapeutic options for congenital hemangioma

RICH may involute spontaneously and often require no intervention

NICH and PICH may persist and, due to high flow vascularity and risk of bleeding, are more often managed surgically

sclerotherapy may be considered for select pts, but evidence is limited

propanolol and topical timolol are not effective

surgical excision is often curative for NICH and PICH, with success dependent on lesion size and location