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PRINCIPLES

PRINCIPLES. OF DIFFERENTIAL DIAGNOSIS AND BIOPSY TECHNIQUES. DIFFERRENTIAL DIAGNOSIS. The application of knowledge and logic to make a clinical decision Follows the hx. and phys. exam and preceeds the radiographic exam, lab studies, bx. and special tests

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PRINCIPLES

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  1. PRINCIPLES OF DIFFERENTIAL DIAGNOSIS AND BIOPSY TECHNIQUES

  2. DIFFERRENTIAL DIAGNOSIS • The application of knowledge and logic to make a clinical decision • Follows the hx. and phys. exam and preceeds the radiographic exam, lab studies, bx. and special tests • IS BASED ON EXCLUSION and those entities that cannot be excluded make up the initial differential dx.

  3. Pre-existing medical condition can effect surgical modalities and may be predictive of morbidity. Exam: congenital heart lesions, Htn, coagulopathies The oral lesion may be a manifestation of systemic dz. Exam: leukemia, lichen planis, Chrohn’s dz, hairy leukoplakia 80-90% of syst. dzs. can be discovered by thorough med hx IMPORTANCE OF THE MEDICAL HISTORY

  4. LESIONS-PHYSICAL FINDINGS • Divide into 3 categories 1) Surface lesions of the mucosa and epidermis. Usually do not exceed 2mm in thickness. Divided into 3 categories based on clinical appearance: white; pigmented (brown/blue/red/black); vesicular/ulcerated/erythematous 2) Soft tissue enlargements

  5. LESIONS-PHYSICAL FINDINGS • 2) Soft tissue enlargements an be divided into reactive or neoplastic. Benign lesions with slow growth, not fixed, move teeth and mucosa normal. Malignant lesions may show rapid growth, ulceration, loosen teeth and systemic symptoms

  6. LESIONS-PHYSICAL FINDINGS • 3)Intraosseous lesions. With the exception of lesions associated with a necrotic pulp, are less common than ST lesions. Are classified into 5 categories: cysts, odontogenic tumors, benign nonodontogenic tumors, malignant tumors, and dzs. of bone. Pain, paresthesia, growth rate, mucosa involvement are important sxs.

  7. LESIONS-CHARACTERISTICS • Duration of existence • Change in size/rate of change • Change in character vesicle/ lump/ ulcer • Sys.: pain, paresthesia,smell/ taste, adenopathy, associated constitutional changes • Any historic reason for lesion

  8. CLINICAL EXAMINATION • Classically involves inspection, palpation, percussion, and auscultation • Also evaluate: anatomic location of mass, overall physical character of lesion, color, sharpness of boundaries, consistency, presence of fluctuance/pulsation and lymph node adenopathy

  9. Longevity of 2 weeks or > Persistent keratotic changes Persistent swelling Interference with function Malignancy? Erythroplasia or speckled. Ulceration. Duration > 2weeks. Rapid growth rate. Bleeding with manipulation. Induration or fixation INDICATIONS FOR BIOPSY

  10. PRINCIPLES OF BIOPSY • 4 MAJOR TYPES OF BX AROUND THE ORAL CAVITY 1)Oral cytology-exfoliative cytology and oral brush cytology. IS NOT A SUBSTITUTE FOR TRADITIONAL SCALPEL BIOPSY AND HISTOLOGY 2)Aspiration- 18 g needle/10 cc barrel For any osseous lucency. Also FNA

  11. TYPES OF BIOPSY CON’T • 3) Incisional: samples a representative portion of lesion. Indicated for those lesions larger than one cm, hazardous location, suspected malignancy. Better if wedge-shaped, deep and narrow with area showing complete tissue changes. Never use necrotic tissue, gingival crevice, attached gingiva if possible

  12. TYPES OF BIOPSY CON’T • 4)Excisional: implies removal of the entire lesion so a perimeter of normal tissue surrounding the lesion(2-3mm) is included to ensure total removal. Indications include lesion < 1 cm, probable benign process.

  13. Block anesthesia preferred, but if infiltration used must be ~1 cm from lesion Stabilize the tissue being excised ie chalazeon/suture/towel clip Hemostasis: suction may not be your friend Incision: sharp scalpel, avoid electrocautery & most lasers. Parallel to normal course of nerves/vessels! BIOPSY-SURGICAL PRINCIPLES

  14. Handling of tissues: DO NOT CRUSH esp with tissue forceps/curved kelly Identify margins i.e. buccal/lingual/proximal/deep etc Specimen care: formalin/saline and not on wall of container but fully immersed Primary closure is the aim BIOPSY-SURGICAL PRINCIPLES

  15. Palpate the jaws where lesion is located-hard or spongy(implies cortical expansion) If radiolucent-ASPIRATE-straw-colored vs air vs cheesy vs heme Mucoperiosteal flaps- over sound bone and avoid major neurovascular structures Removal of specimen-incisional vs excisional Specimen reading will take longer INTRAOSSEOUS/HARD TISSUE BIOPSY

  16. WHITE SURFACE LESIONS • Lichen planis-bilateral distribution • Nic. Stomatitis-hard palate/smoker • Hairy leukoplakia-immunosuppression • Leukoplakias-malignancy? • Surface debris: candidiasis, burns • Subepithelial:Fordyce granules, fibrosis

  17. LOCALIZED SURFACE PIGMENTATION • Varix, hemangioma, hematoma, ecchymosis, petechiae • Melanin: Lentigo simplex, nevus, melanoma. Systemic dzs assd with melanosis incl. Peutz Jeghers syndr., multiple neurofibromatosis, pregnancy, fibrous dysplasia, medication • Amalgam tattoo

  18. Reactive: what is tissue reacting to e.g. bacterial,physical, chemical etc Neoplastic: if it appears malignant-incisional bx If neoplasia appears benign, divide into 4 categories 1)surface epithelial:papilloma, condyloma, keratoacanthoma,verrucous Ca. 2) mesenchymal: neurofibroma,fibroma,hemangioma,pyogenic granuloma SOFT TISSUE ENLARGEMENTS

  19. SOFT TISSUE ENLARGEMENTS CON’T • Neoplasia con’t: 3) salivary gland neoplasia-pleomorphic adenoma 4) Cysts of soft tissues-epidermal inclusion cyst, thyroglossal duct cyst, gingival cyst, nasolabial, dermoid

  20. SURGICAL MANAGEMENT OF CYSTS • Stepwise approach i.e. physical exam to include inspect/palpate/auscultate • Aspirate with 18g If no aspirate, lesion may be a tumor and incisional bx indicated. If air, probable traumatic bone cyst. If fluid:yellow vs opaque/cheesy vs blood

  21. CYST TREATMENT • Elimination is the aim. May be accomplished by decompression, marsupialization and enucleation • Decompression: flap, aspirate, open into cyst, maintain drainage over weeks to months. Difficult secondary to hygiene problems and if inadequate bx specimen, the lining will continue to propogate.

  22. CYST TREATMENT CON’T • Marsupialization: is exteriorizing the cyst. It differs from decompression in that the roof of the cyst is removed and an synthetic tube is sewed into place and daily hygiene is maintained. The tube is prone to displacement • Enucleation: Removal en toto

  23. CYST TREATMENT CON’T • If you suspect an OKC: after enucleation, a peripheral ostectomy must be accomplished with burrs, use of chemicals (phenol or Carnoy’s solution) cryosurgery, or electrosurgery. If the OKC recurs more than 2x, resect

  24. BIOPSY TECHNIQUE PRESENTATION OF CASES

  25. Pathology??

  26. MALIGNANT MELANOMA

  27. OCULAR FUNGATING MALIGNANCY

  28. AMELOBLASTOMA-CHINA STYLE

  29. EXCISIONAL BIOPSY

  30. SQUAMOUS CELL CA.

  31. KERATOACANTHOMA

  32. PLEOMORPHIC ADENOMA

  33. PATIENT COMFORT DURING HEALING PHASE IMPORTANT

  34. CYST THERAPY 18 GAUGE ASPIRATION

  35. CENTRAL GIANT CELL GRANULOMA

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