Overview of Oral Surgery, Biopsies
A biopsy is a medical procedure where a small amount of tissue is taken from the body, so doctors can study it and better understand what might be causing the patient’s symptoms. Doctors use it to find out more about things going on in your head and neck. Of course, before they dive in, they will get a clear medical history from you. This involves understanding your symptoms, what makes them better or worse, along with any other medical conditions you might have. This information helps the doctors make a more accurate guess about what might be wrong.
There are two main types of biopsies they might do in your mouth and neck. One is a soft tissue biopsy, which gets tissue from places like your tongue or gums. The second is a hard tissue biopsy that takes samples from bone structures or bone marrow.
Before starting a biopsy on a hard tissue, doctors will usually recommend getting a scan of the area to see how big it is and help them plan out how to do it. This scan could be a panoramic dental x-ray or a Cone-Beam Computed Tomography scan. Sometimes, Computed Tomography scans might be necessary for more serious hard tissue issues, but this isn’t usually recommended if there’s a suspected infection like osteomyelitis.
Generally, doctors use three common types of biopsies. The first one is fine needle aspiration (FNA). They perform this by inserting a hollow needle into the lesion or lump several times and collecting small tissue fragments for analysis. However, it’s worth noting that this method doesn’t provide enough tissue for a definite diagnosis. Instead, it’s used to decide if the lump is harmless or malignant (cancerous), helping to plan further treatments.
The second common biopsy is a core biopsy. This type is just like the FNA but provides a larger tissue sample, allowing for a confirmed diagnosis of the issue. This service might be offered by the Interventional Radiology department in some hospitals.
Lastly, a brush biopsy is another method used. It uses a special brush to collect cells from soft tissue lesions for analysis. While this could become a more standard and less invasive approach in the future, it’s not currently top of the list due to limited supporting evidence.
Anatomy and Physiology of Oral Surgery, Biopsies
The inside of your mouth is made up of several soft tissues, including the lining of your cheeks, tongue, and gums. The lining of your cheeks, the area surrounding your teeth, and the ridges of your jaw, and the inside of your lips have a softer, more flexible type of skin than the skin on your gums and the roof of your mouth. This difference can be seen during a regular oral exam.
The floor of your mouth is also covered with a softer kind of skin, with a few salivary ducts (tubes that carry saliva from the glands to the mouth) poking through. The skins on the top and bottom of the tongue are different from each other.
The cells in your mouth regenerate every two to three weeks, which makes it heal very quickly. This is why if a doctor takes a tissue sample from the mouth (a biopsy), it doesn’t hurt for very long.
A biopsy in the mouth is generally easy and safe, though risks can arise if important structures are damaged during the procedure. If a deeper biopsy is required, such as on the lip, it can lead to more bleeding and potentially damage nearby arteries. Extra care will be needed when taking a biopsy from the cheek, as not to damage the parotid duct, a crucial part of our salivary gland system.
Gum and palate biopsies are typically straightforward. However, damage to certain nerves and blood vessels that run near specific teeth can be risky. Also, due to the nature of the tissue on the hard palate, the biopsy site can’t usually be closed up afterward.
The tongue has an amazing ability to regenerate itself, which is why biopsies can conveniently be taken from its surface. This is especially important as the most common location of oral cancer is on the edge of the tongue, making frequent biopsies necessary for suspicious looking areas.
The floor of the mouth is the trickiest area to do a biopsy on, as its skin is thin and delicate, and there are various important structures underneath like salivary ducts, nerves, and blood vessels. Less experienced doctors could potentially risk injuring these structures.
Doctors suggest a biopsy for any mouth lesion (an unusual patch of skin) that stays for more than two weeks. Most benign (non-cancerous) lesions are painless and often pink, similar to the color of normal mouth skin. These can resemble fibromas, granulomas, or mucoceles. Other lesions might indicate blocked salivary glands or a viral infection.
Ulcerations (broken skin or open sores) are common in cancerous conditions and should be evaluated further. However, there can be many other non-cancerous reasons as well for these ulcerations.
Lesions on the jaw ridge might signal infections that have spread from a decayed tooth or the bone itself. Also, any lumps on the side of the tongue that is painful, accompanied by other symptoms such as difficulty swallowing, weight loss, or bleeding should be biopsied. Red or purple tumors could suggest a vascular lesion (related to blood vessels), requiring caution and a CT scan for confirmation.
Any lesion appearing as purple, dark blue, or black should be biopsied as they can be an indication of oral melanoma (a dangerous type of skin cancer). However, often these are just harmless metal fragments left behind from previous dental treatments known as amalgam tattoos.
The hard structures in your mouth are primarily your teeth and jaw bones, which can sometimes be the source of lesions, particularly in cases of localized infections.
Why do People Need Oral Surgery, Biopsies
Before a biopsy can be planned, your doctor needs to gather a full medical history, conduct a clinical exam, and examine any radiographic (x-ray) images. They’ll also interpret any necessary laboratory tests. The doctor has to obtain your consent before they can proceed. They’ll explain possible diagnoses, the risks and benefits, other options, any complications, and what the biopsy procedure entails.
A biopsy involves taking a small sample of a hard or soft tissue that has been present for two weeks or more. This method is often used because conditions that will heal without intervention usually do so within two weeks. If the lesion or suspicious area is new, simply monitoring the condition closely could be sufficient. In certain cases, a patient may opt for a biopsy on a lesion that is likely benign (non-threatening) in order to alleviate their worry. These decisions should be made through a discussion between the patient and doctor, and all decision-making should be documented in your medical records.
When a Person Should Avoid Oral Surgery, Biopsies
The reasons that a biopsy (a medical test involving taking a small sample of tissue for examination) of parts within the mouth can’t be done are pretty limited. Mostly, it depends on what kind of biopsy is being done and how familiar the doctor is with doing this specific procedure. If they don’t have much experience with the area where the test is meant to be taken, it’s a good idea for the patient to see another doctor who specializes in this area.
But there are a few specific conditions which might make a biopsy more complex.
Firstly, there are vascular malformations – these are abnormalities in blood vessels that could show up as hard or soft lumps. Soft lumps might show some signs such as a vibration or sound when touched, become paler when pressed, and be related to arteries, veins, or both. Hard, bony lumps may lead to pain, bleeding, and loose teeth. Whenever a doctor suspects you have such a condition, they might perform a type of imaging test called a CT angiography and consult with a radiologist to see if it’s necessary to block the blood flow to the malformation before attempting to remove it. It’s also strongly recommended to do this in an operating room because there could be significant blood loss.
Bony vascular malformations can be more challenging than those in the soft tissues, as bleeding during the operation can be hard to control. If the doctor attempting to biopsy a bony lesion draws blood, it suggests that the lesion might be vascular, and they should stop the procedure and investigate further.
Potentially cancerous lesions also need special care. Signs of cancer include pain, changed sensation like numbness, ulcers with a distinct edge, and bone damage that has a ‘moth-eaten’ look. Doctors should be familiar with the guidelines in their country for investigating suspected cancer; in the US, for example, the National Comprehensive Cancer Network offers free guidelines online. When biopsying a potentially cancerous lesion, it’s important to document the details of the lesion and the biopsy procedure, and take pictures for future reference.
Lastly, conditions like bone infections, damage from radiation treatment, and drug-related bone damage in the jaw need special care and evaluation that goes beyond what’s covered here.
Equipment used for Oral Surgery, Biopsies
In simple terms, when a doctor suspects disease or infection within your body’s soft or hard tissue, they might need to do a biopsy. This is a medical procedure where a small sample of the suspect tissue is removed so it can be examined in more detail in a lab. This helps the doctor arrive at a diagnosis and determine how to treat the problem.
Soft Tissue Biopsies
Biopsies of soft tissue are usually performed in a clinic and the patient doesn’t need to stay overnight. The area is numbed with local anaesthesia so the process isn’t painful. If possible, the entire suspected lesion (damaged or unhealthy area) is removed and sent for testing.
The doctor will use various pieces of equipment including a local anesthetic to numb the area, a type of scalpel for the incision, and small tools like forceps and scissors to perform the procedure. They would then use sutures (a kind of stitch), to close the wound. An electrocautery device, which controls bleeding by heating the body’s tissues, should be readily available just in case it’s needed.
Hard Tissue Biopsies
In contrast, if the biopsy is to be taken from hard tissue, such as bone, it requires more planning. The decision on whether to try and remove the whole lesion or just a sample (incisional biopsy), is usually made as the procedure unfolds.
If the bone lesion contains yellow or clear fluid, it might be indicative of ‘cystic pathology’ which is a disease that forms small closed sacs filled with fluid or a solid material. In that case, the entire lesion is removed. Following this, depending on the state of the remaining bone, the doctor might decide to fill the area with ‘bone grafting’ and might even need to stabilize the upper or lower jaw with metal hardware.
If the lesion is solid instead of liquid-filled, then an incisional biopsy may be performed to send a small part of the lesion for testing.
In addition to the tools used in a soft tissue biopsy, this procedure also requires burrs (tools used to cut or shape bone), a needle and syringe, and hemostats, which are tools to control bleeding.
Transporting the Sample
The sample removed during the biopsy will need to be properly packaged for transport. If typical evaluation is needed, it is placed in a solution called ‘formalin.’ However, if an immune-related issue is suspected like lichen planus, pemphigus vulgaris, mucous membrane pemphigoid, or lupus, a separate tissue sample is obtained and placed in ‘Michel solution.’ If you are in a facility with an onsite pathologist, an immediate assessment may be possible to check if the lesion is malignant (cancerous).
How is Oral Surgery, Biopsies performed
Biopsies are performed to remove tissue to be tested for diseases, including cancer. We have two main types of biopsies to discuss: Soft tissue biopsy and bony tissue biopsy.
Soft Tissue Biopsy
Superior to alternatives like localized anesthetics, field anesthetic infiltration or regional anesthetic blocks can make the biopsy less distorted and easier to handle. In most instances, an excisional biopsy performs an ellipse-shaped cut around the lesion – that’s an oval shape with pointed ends. This allows easier wound closure and better cosmetic finish.
When removing lesions on the lips, it’s best to use a vertical ellipse to promote better healing and cosmetic outcome. For facial skin, the biopsy should go along natural skin tension lines for better aesthetic results. The cut is usually made with a 15-blade scalpel and dissected sharply for best tissue removal.
Excessive use of electrocautery (use of heat for tissue removal) should be avoided, to not distort the tissue that needs to be examined. After the removal of the lesion, the wound should be washed out properly, and any bleeding should be stopped before it’s stitched up.
In more serious cases, where the doctor suspects cancer, an incisional biopsy is recommended. It’s very important for the doctor to capture both normal and abnormal tissue during this procedure for better examination later on. In such cases, photographs are often taken for future reference and the specimens are oriented, or placed in a way that reflects their original position in the body.
Bony Lesion
When a biopsy is performed on the bone, careful planning of the procedure is crucial. This includes the size and design of the incision, bone entry location, and also which tools and techniques to use based on what they find during the surgery.
After the part of the bone with the lesion is exposed, a needle is used to aspirate, or draw out fluid from the exact spot. Depending on the resulting fluid, it can indicate different conditions. For instance, if the substance resembles cottage cheese, it could be an odontogenic keratocyst.
Depending on the condition, the surgeon might decide to remove the whole lesion (excisional biopsy) or just a small part of it (incisional biopsy). In some situations, especially when dealing with the jaw, extra caution should be taken to avoid any injury to important nerves during the dissection.
Finally, depending on the strength and integrity of the remaining bone structure, bone grafting or plating could be required to avoid fractures and promote proper healing.
Marsupialization and Drain Placement
Alternative treatments to biopsy include decompression via marsupialization or drain placement. These procedures essentially remove pressure from the lesion and may cause it to shrink over time. Marsupialization can be considered for large ranulas and other pathologies of the floor of the mouth. It involves the incision of the lesion and suturing of its edges to the surrounding so it can drain freely, decompress, and shrink with time.
Possible Complications of Oral Surgery, Biopsies
When taking a sample of unusual tissue, or a biopsy, within the mouth, there might be some possible complications. It’s essential to talk about these risks and make sure they’re correctly recorded before you go through with the procedure. The side effects can include bleeding, infection, pain, swelling, and even damage to nearby areas such as teeth. There could also be temporary or long-term harm to the nerves that control sensation and movement. In some cases, you might have to be admitted to hospital or need more surgery. If the sample is planned to be taken through a small cut, or incisional biopsy, you may require additional procedures in the future. If grafting is performed, which involves replacing or reinforcing damaged tissue, there is a risk of infection or failure of the graft.
What Else Should I Know About Oral Surgery, Biopsies?
Head and neck diseases make up a substantial part of the work that head and neck surgeons do. Understanding how to perform and interpret biopsies – these are procedures where a small sample of tissue is removed for examination – is crucial to plan the best possible treatment that ensures patient safety.
Diseases in the head and neck can be anything from harmless conditions needing regular check-ups to malignant (cancerous) tumors that need significant medical and surgical management. The first step to treating any disease in this area usually involves an initial evaluation and biopsy.
Doctors must fully understand the reasons behind performing a biopsy. This includes considering a patient’s medical history, known risk factors, age, symptoms, and any imaging tests done. Such considerations help guide not only where the biopsy should be taken from but also how it should be taken. Doctors should also be skilled enough to carry out different kinds of biopsies and to recognize and manage any possible complications. More importantly, if a doctor cannot manage the disease themselves, they should be able to refer the patient to someone who can.
