05: diagnostic procedures ii

Transcribed by Anam Khalid Monday, July 7th, 2014

[Diagnosis and Treatment of Oral Diseases] [Lecture #5] – [Surgical Oral Biopsy Technique] by [Dr. S. Shah]

[1] – [Surgical Oral Biopsy Technique][Dr. Shah] – Okay, you guys ready for part 2? Yes, no? Okay, let’s do it. Once you guys are ready to begin, let me know. Okay. Surgical oral biopsy technique. Okay, so this last lecture, I talked … you know, a couple minutes ago … we talked about the techniques but now I want to go more … if you’re going to do a scalpel biopsy, incisional or excisional biopsy, what is the technique? What is the procedure? And then I want to go over that word, “representative.” If you’re going to do an incisional biopsy, how do you know which site to biopsy? And that is the purpose of this lecture here. Surgical oral biopsy technique.

[2] – [Indications for Biopsy][Dr. Shah] – Okay, so indications for biopsy. There is a general, two-week golden rule. Two-week golden rule. Okay? Where if you have something that’s a suspicious finding. Okay? And let’s say that maybe you know, maybe there was a possible cause, a sharp or broken tooth, or maybe it was an ulcer or something, maybe you smooth the teeth, maybe you tell the patient not to bite the area. You try to remove the cause and then you have the patient come back in two weeks. If it doesn’t look any better, then according to the two-week golden rule, you’re supposed to do a biopsy on that. Okay? Then another indication for biopsy is obviously lesions in high-risk areas and then suspicious lesions. Okay, what are suspicious lesions? Okay? That is an important topic.

[2] – [Characteristics of Suspicious Lesions][Dr. Shah] – Characteristics of suspicious lesions. So, erythroplasia. What does erythroplasia mean? It means there’s a red component. Okay? So, if the lesion is totally red, that’s called erythroplakia. Or has a speckled red appearance, erythroleukoplakia, where you can have a red and white component. Any redness is suspicious. Okay? So, ulceration, if a lesion is ulcerated or presents as an ulcer, that’s a suspicious finding as well. Long duration, if a lesion has persisted for more than two weeks with no change even though you tried to change, you know, some biting habit or some sharp or broken tooth or something along those lines. Fast growth rate, something is growing pretty quickly or increasing in size pretty quickly. Bleeding, if something bleeds on gentle manipulation, that’s not a good sign. Okay? As you should know, tumors and malignancies, angiogenesis, they have a supply of extra blood vessels. So these things bleed easily. And there’s another word for that: friability. Friability. The tissue falls apart and bleeds easily. Induration is another characteristic of suspicious lesions. Induration is when the lesion and the surrounding tissue is firm to the touch. So, we talked about this when I was talking about the lip cancers, remember? I said when you feel the lip, it feels soft and all of a sudden, you’ll feel a really firm area that feels fixed? That’s called indurated. Okay? And then fixation means when something doesn’t move. It’s attached to the adjacent structures. So these are your characteristics of suspicious lesions. Yes, sir?[Student] – That top, when you want to say erythroplakia, it says erythroplasia …

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[Dr. Shah] – Okay, so, erythroplasia just means it’s a general term for redness. Okay? A red component. Erythroplakia is a flat red lesion. Okay? So it’s just a little bit of terminology there. Okay. So characteristics of suspicious lesions.

[4] – [General Biopsy Principles][Dr. Shah] – Now I want to talk about general biopsy principles. Okay? So these are all general surgical principles. These are the same principles you use when you’re extracting a tooth or when you’re doing any type of perio surgery or any surgical procedure, actually anywhere on the body, not just the oral cavity. General surgical principles. Okay, so when you’re doing a biopsy, you should avoid ulcerated, necrotic, areas. Okay? We talked about this with brush biopsy but even with the scalpel biopsy, if you biopsy straight into an ulcer you’re not going to get … as I said all I’m going to see on the microscope is some necrotic tissue and inflammatory cells. It’s not going to be anything. Okay? So you can biopsy the edge of an ulcer. Okay? Which is a good idea. Okay? But not straight into an ulcer. Take a wedge of tissue. And actually, I want to go back to that, the ulcerated thing for a second. There are some exceptions to the rule. Some squamous cell carcinomas will just present as this huge ulcer. Then you sort of do have to go a little bit into the ulcer but you still want to go on a border, to tell you the truth. Okay? The next principle: you want to take a wedge of tissue. What do I mean by wedge? I mean a narrow, deep specimen is better than a broad, shallow specimen. Okay? So it’s better to go deeper than to go broader and shallower. Okay. And then another general biopsy principle is to select the worst looking area to biopsy. Okay? Worst looking is something that you have to learn. What is worst looking? It isn’t just, you know, what doesn’t appeal to your eye but there’s actually some technique to this. Red areas are better to biopsy than white areas and rough surface areas are better than smooth areas. Okay? These are just two general rules for finding the worst looking area. Red is worse than white, rough is worse than smooth. Okay? Multiple areas may be biopsied when the lesion is large or shows significant variation. Okay? So if you have a lesion that’s pretty big, there is no rule that says you can’t biopsy more than one site. You can and maybe you should. Okay? Always be aware of regional anatomy. You have to know, you have to have some anatomy knowledge. You guys all took an anatomy course last year, right? So you have to have a sense of where nerves run, where blood vessels are when you do these biopsies. Okay?

[5] – [Incisional Biopsy Technique][Dr. Shah] – Incisional biopsy technique, here’s just a little basic diagram to show you. Desirable is narrow and deep, you’re going, you know … this is epithelium and this is connective. You’re going deep. Here, this is broad and shallow so it’s better to go narrow and deep. Okay.

[6] – [Biopsy Site Selection: Red Area][Dr. Shah] – Now I’m going to go over some lesions and show you what is the best site to biopsy. Okay? So these are representative sites or worse looking areas. So here you have a lesion, right? On the lateral border of the tongue. It’s red and it’s white and it’s ulcerated in some areas. This is an actual ulcer, we’re missing

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epithelium. There’s some white changes. There’s some red areas. So, you know, what’s one of the better sites to biopsy here? I circled this because I would go for this red area here. Okay? So red is better to biopsy than white and it’s considered worse looking.

[7] – [Biopsy Site Selection: Rough Area][Dr. Shah] – Alright. Here’s a lesion that’s on the ventral border of the tongue. Ventral surface of the tongue, I’m sorry. You have a leukoplakia here, right? It’s got some smooth areas, it’s got some rough areas. So I would choose to biopsy this area, which is a little rough in surface. So rough is better to biopsy than smooth. Here’s another example. We’re looking at some multiple lesions on the lateral border of the tongue, which is a high-risk site for pre-cancers and cancers. I choose to biopsy this site because it’s very rough and a little exophitic. And actually when I feel it, it feels a little firm, indurated, or a little thicker than this area. This is a smooth, thin leukoplakia. So if I had to pick between this and this, I would pick this to biopsy. Okay? Are you guys with me so far? Yea.

[Student] -- Shouldn’t that be like [unintelligible] … symptoms?

[Dr. Shah]—It could. And you could do two biopsies. That really is a good point. But again, tongue biopsies, the tongue bleeds a lot and so you may or may not want to two biopsies at the same time in a patient. Especially if they have a complex medical history but you’re right. This could be two totally different things. This could be from biting and this could actually be a dysplasia or vice a versa. So the truth is you probably should biopsy this as well. But I’m trying to illustrate a point here that let’s say I could do only one biopsy due to patient factors, or paying for it, or whatever it is. I would choose to go in this rough, white area than this smooth area. Okay? But very good question. Okay.

[8] – [Biopsy Site Selection: Peri-ulcer][Dr. Shah] – Another thing, let’s say you have a white lesion and there’s an ulcer. Where would you choose to biopsy? I would choose to go near the ulcer. Okay? So peri-ulcer. Not in the ulcer, but around the ulcer. Okay? So, this is an ulcerated area, so here we’re around the ulcer. This is a nice black and white kind of shot of this and it helps you to see where the ulcer is. Okay? You can see the ulcer right there so I’m going around the ulcer and getting a border of the ulcer here. But not just straight into the ulcer.

[9] – [Biopsy Site Selection: Velscope and T Blue][Dr. Shah] – Okay, then there’s something else, Dr. Kerr, who is my colleague, you know, he’s an oral cancer and pre-cancer expert and he’s going to be giving you a lecture pretty soon. We have these two special tests, I don’t know if any of you have ever heard of these: Velscope and Toluidine Blue. Anyone? Okay, they’re going to go into a lot more detail about this shortly. Okay? So do not panic, you know, if you don’t know what this is. Right now, I’m just barely covering it. Velscope is a special light that you use and wherever you see black areas, those are suspicious areas that

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you should biopsy. Okay and T blue is a blue stain that wherever it stains blue, darker blue, those are suspicious areas that you should biopsy. Okay? So we use these tests in the oral medicine clinic and in our BlueStone Center for oral cancer and pre-cancer. Okay, so these are dark areas, so in this lesion, these are good areas to biopsy. Okay? This is T blue staining; wherever it’s positive might be good areas to biopsy, okay?

[10] – [Biopsy Site Selection: Striated Areas for Lichenoid Lesions][Dr. Shah] – Alright. Something else, let’s say you have a lichenoid lesion. Remember, we talked about … I just barely talked about Lichens planus and the striae that you can find on the buccal mucosa? I’m going to talk more about Lichen planus on Monday but where should you biopsy those lesions? You should actually biopsy the white striae. So let’s say you have this, you know, radiating white striae on the buccal mucosa. There’s some erythema. The erythema is inflammation so to get a good diagnosis, you want to biopsy the actual white striae. Okay. When you’re trying to biopsy something lichenoid. Here is another example. Here you have something that’s erosive, which means there’s an ulcer here and here. There’s red and white areas. I choose to biopsy an area that’s just white striae that’s not ulcerated and that’s not erythematous because that’s just going to give me inflammation and obscure the histology. So it’s very important for lichenoid lesions to biopsy the white striated area. Okay?

[11] – [Biopsy Site Selection: Perilesional for Pemphigus/Penphigoid][Dr. Shah] –Alright. Also, there’s two other conditions. These are skin diseases that can also affect the mouth called Pemphigus and Pemphigoid and again, I’m going to go into more detail on Monday, next Monday, about these two conditions but I just want to show you for the sake of this lecture. That where you see … if you’re suspecting these diseases and you have these lesions here, you want to go perilesional. Perilesional means around the lesion, not straight in the lesion but around the lesion. Okay? So here you have … in these diseases you have peeling of the mucosa and skin. Okay? That’s really what … they’re vesicular, bollus diseases where you get blisters and then the skin just sloughs off. Okay? So that’s what’s happening here in the oral cavity. So you want to go around it, not in it. Because when you go in it, the epithelium has fallen off and we need the epithelium to make the diagnosis of these two diseases. Okay? So perilesional. Here’s another example of going near an affected area, okay? But not straight into the affected area. Yes?

[Student]—do you go into it that … [unintelligible] ... or just maxillary?

[Dr. Shah]—You can take… you take a border of it. Perilesional. Right around the lesion. Take a little bit of that tissue as well, okay? But the greater part of your biopsy should be the normal tissue around the site because you want that epithelium. In the areas that are red, the epithelium has already sloughed and peeled off, okay?

[12] – [Biopsy Studies]

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[Dr. Shah] –I talked about biopsy site selection but now I want to go over the actual process of doing a biopsy. Okay? And this is important and you guys should when you get into private practice be doing biopsies. I have to tell you that, you know, most people just send it straight to an oral surgeon or to an oral medicine, oral pathologist expert. But you can do these things and you should, you know? Again, remember, DDS, doctor of dental surgery. Surgery. We don’t just have to do fillings and crowns and bridges. These things can really affect patient’s lives. And you can really make a difference. Alright, so now I want to go over the procedure but with that said I have to tell you that you guys don’t generally get a lot of opportunities to practice biopsies at this school because it goes to the oral surgeons or it goes to faculty such as myself. But I want to point something out to you; I do run two honors programs, third year and fourth year. And my honors students get to do biopsies in my clinic so if it’s something that you’re interested in in the future, keep that in mind. Okay? But otherwise, you don’t get much experience, unfortunately, with biopsies. Alright. So this is the procedure. This is the equipment that you need to have. You have to have a blade handle with a number 15 blade. I’m going to tell you there’s those disposable blades out there and each person has their own preference. I hate disposable blades because then I never find the blade sharp enough. Okay? So I like the steel handles and the number 15 blade on it. Okay. Then you need a soft tissue forceps to hold the tissue. It should have some teeth on it, something to give you grip of the tissue. Now, with that said, it shouldn’t have, you know, really sharp or too many teeth where you’re just crushing and destroying the tissue. Okay, then you’re going to need, you probably should numb your patient. So, you should have some local anesthetic solution and syringe. Okay, retractor. You’ll need something to hold the tissue. You need a suction source and a surgical suction tip. Anytime, we do a biopsy, we don’t use the normal, you know, suction evacuator or whatever. You need an actual surgical suction tip. There’s in the school the green one and the blue one. Okay? We like the blue one because it has a narrower tip. So tell me, why, if I’m doing a biopsy do I want a surgical suction with a narrow tip? Simple reason, really. Yea, I don’t want it to suck up my 4 or 5 mm biopsy and believe me, it’s happened before. Okay? And you don’t want that … that’s a hard one to explain to patients so you really don’t want that to happen. So, the surgical suction tip has a really small opening, okay? Gauze. You’re going to need gauze for hemostasis, for drying the tissue, and for retraction. Sutures can be used … traction means holding the tissue and obviously, closure. If indicated … I have to tell you that for many oral biopsies, we don’t even suture. I think I barely suture 10% of all the biopsies I do. Okay? Because a lot of them are punches and if you do a punch, you get a nice round hole. You can’t suture that together; you don’t have edges to suture together. And most oral biopsies are so superficial that gauze pressure can lead to hemostasis so you don’t really have to suture it and they heal quite well. Okay? But occasionally, you know, when we’re doing a large soft tissue lesion or something along those lines, you do have to suture it. And again, when you go in the oral surgery, you’re going to learn more about this but sutures, it’s by preference, really. They come in different materials, they come in different thicknesses. Some of them are resorbable, some of them are not. I personally prefer threo silk. I love silk. Silk is easily maneuverable. Okay, chromic gut and Vikril (?), they’re really thick and they’re really bulky and

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they’re hard to make a good knot. And I think you get much better results with silk. Okay? So, again, when you do oral surgery you’re going to find what you like and go there. Also, I’ll tell you one more thing: resorbable sutures, I really don’t like from a pathology point of view because what happens, and I’ve seen the tissues under the microscope, they don’t fully resorb and you get a huge inflammatory reaction around it and a bump and I’ve seen these biopsied and under the microscope where I can see suture bits and then inflammatory cells around it. So I truly believe and another great reason to use silk is my patient has to come back a week later for suture removal and that way I can really keep track of them and give them the results. So if you think about it, silk is really a great option. There’s only 1 downfall, who knows what it is? And that’s a real downfall at this school here … it’s really expensive, yea. That’s the only issue that I see for silk, okay? Let’s see, so we talked about sutures, okay. And then you also have to have, obviously you have to have a bottle to put the biopsy in. specimen bottle containing formalin. It should be labeled and there should be a sheet with it that you put the name and the clinical information on. Okay?

[13] – [Biopsy Supplies][Dr. Shah] – Alright. Here’s a picture showing you the biopsy supplies here. It isn’t always so beautifully laid out like this. And we don’t use all these things but this is the biopsy bottle, this is obviously the syringe, okay? And I want to point out one thing; we usually use 1 to 100,000, I mean a 2% lidocaine with a 1 to 100,000 epinephrine, which is your normal dental anesthetic. Okay? However, when I do a tongue biopsy, again, personal choice because it bleeds more I move to 1 to 50,000 epinephrine so I can control the bleeding a little bit better. Okay? Then you have various hemostats here. Here you have your scalpel. This is a retractor. These are cotton pliers. I like the smaller, soft tissue forceps. It’s not on the tray here but it’s half the size of this so I can really manipulate well and not have this long handle because the further away you are from the lesion, the less control you have. Okay? And then, these are some sutures, I can’t tell from this magnification. I think they’re chromic gut (?) which would never be on my table but … and then … who knows what these are? These two things here. Anyone know what these are? Silver nitrate sticks. Okay? Sometimes I use these, normally you don’t have to but it’s for cauterizing. It burns the tissue and burns the blood vessels if you have a bleeding issue and you can’t hemostasis. Okay? However, this should not be sitting on the bracket table because it’s photosensitive and it’s being used up here. So it’s normally in a dark container and should only be taken out right before use. Okay? So this is not good. Alright? And here’s the setup in a tray here. And this is great, threo silk. That’s a good one.

[14] – [Preliminary Steps][Dr. Shah] – Preliminary steps. Okay, so now let’s say you know you decided that you want to do a biopsy. You should know the patient’s medical history. Never treat a stranger. I’m sure you’ve heard that rule before, or you will. You have to know what you’re doing and who you’re dealing with and what their medical history is. Okay? So make sure the patient has no coagulopathy. What does coagulopathy mean?

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Problems with clotting. Okay, so, obviously, a biopsy is a surgical procedure. You want to make sure your patient is able to clot so you … I probably would think long and hard before I decided to do a biopsy on a patient that’s on Warfarin, or Coumadin, or Plavix or one of those blood thinners or high-dose aspirin. You really have to think about that because the worse thing you can do is try to biopsy something and then cause a bleeding issue and cause harm, right? We always take a blood pressure before we do a biopsy. Always. Doesn’t matter if the patient says they feel fine, doesn’t matter if the patient is young and healthy looking. You always take a blood pressure. You should always take a blood pressure, it’s not always what happens, but you should. Okay, obtain informed consent. Okay? This is a procedure that you are doing that requires consent. You have to have the patient sign a consent form. And on the consent form, you have to specifically write what you’re doing. So the school has these generic consent forms and the bottom line says treatment. You should not have your patient ... your patient should not be signing that unless on the bottom you’ve written specifically what you’re doing … incisional biopsy of left later tongue, excisional biopsy of nodule on cheek. Whatever. Okay? And then that should be explained to the patient and then the patient signs that. If you have a form where you have not written anything on the bottom and there is a lawsuit or a case, that is malpractice right there. Okay? The patient can easily say I never consented to that, I don’t know what I signed. It doesn’t say anything here. I thought I was just getting dental work. Okay? So you have to make sure that you have that written on the bottom. Okay? So once you’ve got the medical history, blood pressure, consent, now we can actually, you know, get somewhere … get started. But first, before you do that you have to actually plan out how you’re going to do it. You have to have an assistant, somebody who’s going to help you. How are they going to retract the tissue and suction. Okay? Then once you’ve figured all that out, you’re ready to go to local anesthesia. We do use a little topical benzocaine, okay? And then we’re ready to give our anesthesia. Okay.

[15] – [Tissue Stabilization][Dr. Shah] – These are just some pictures showing you some tissue stabilization. Okay? If you have a lesion on the lip, you know, your partner or assistant would be holding it like this with a little bit of tension to keep the tissue a little bit more fixed and firm. Here’s an example. This is a laser. Laser is also used for biopsies. That’s another thing I haven’t really gone into. But laser biopsies are not really recommended because it burns the tissue and under the microscope it can really obscure the diagnosis. But anyway, so you can see someone’s holding it with cotton pliers here while this person is getting ready to remove the lesion. Here’s another example of a tongue lesion and you can see that the assistant is using gauze and holding and stabilizing the tongue for the person who’s going to do the biopsy. Generally when you need a biopsy, it’s very hard to do a biopsy by yourself, it really is. Although I have to say I’ve done it before. But you really should have an assistant or someone, you know, can really help you, a competent assistant, hopefully. Okay.

[16] – [Anesthesia for Oral Biopsies]

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[Dr. Shah] – Anesthesia for oral biopsies. Now we’re ready. How do you do the anesthesia? We usually do, almost always I should say, local infiltration and we want use the least amount of lidocaine with epinephrine. For most oral biopsies, a quarter to half a carpule is all we need; I almost never use more than half a carpule of anesthetic, maybe for a tongue biopsy or maybe for something really big or along those lines. But other than that, a quarter to half a carpule is plenty for any oral biopsy. Okay? So, let me ask you a question: have you guys, probably not, but I have to ask anyway, done anything with anesthesiology yet? Do you know anything about blocks or local infiltration? You guys haven’t done the thing where you do injections on each other yet, right? Okay. Alright. That fun is coming soon. Local infiltration means that you’re injecting right around the lesion, okay? There’s something called blocks. A block is we’re injecting into a nerve opening and you numb the whole nerve. So when we do dental work we normally do blocks, especially if we’re doing mandibular teeth, there’s something called the mandibular block or inferior alveolar nerve block, it numbs that whole side and the side of the tongue and that side of the lip and things like that. It’s the entire nerve. Okay? But when we do oral biopsies, we’re not doing blocks; we’re going right around the lesion and numbing that area. Can you think of why we might do that instead of numbing the whole area? Just think about this, why would you just do that area instead of numbing that whole … whole block? Anyone? Okay, well think about … yea …

[Student]—There are other nerves around there that are not numb for the nerve block?

[Dr. Shah]—Not quite. Okay, think about the vasoconstriction, okay? One of the things is that the epinephrine in the anesthetic helps with vasoconstriction or controlling bleeding at the site of biopsy so that’s why I want to do the infiltration right around where I’m cutting because it’s numb right where I’m cutting and it helps control the bleeding right where I’m cutting, okay? Alright. Never inject directly into a lesion, you always inject around the lesion we’re going to be cutting. You don’t go straight into the lesion, that can distort the tissue and you’re not numbing the area where you’re going to cut. Although, slowly over time it does kind of diffuse anyway but still. Inject slowly so as not to distort the tissue. When you start doing dental injections you’ll see that you don’t want to inject too fast or the whole area just swells up, okay? And it’s really uncomfortable for the patient and it doesn’t diffuse like it should. So you inject slowly. Okay. Inject at multiple points surrounding the lesion. I want to tell you that there are two schools of thought for this. Some people if they have a lesion they just inject under it at an angle and let it diffuse, so just one injection, which is more pleasant for the patient, to tell you the truth. However, other people, including myself, I like to do the four-point, where I actually go four points around it. It is four injections for the patient, it’s a little uncomfortable in the beginning but I know the area is numb and I know my entire area that I’m going to biopsy, I’m going to get vasoconstriction and I prefer to do that. But you’ll see when you do this what you prefer, okay? And it’s important to test the area before proceeding to biopsy. After you did the anesthesia, you really want to like … I usually take a perio probe and test the area and then test the

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surrounding tissue and ask the patient if they feel different. That’s usually how I test it. You could use an explorer but I would advise against it because it has a sharp point and you’re creating little punctate holes and bleeding. So I like to use a perio probe. Okay. So now, after we’ve done the anesthesia, now we’re ready to do the biopsy. It’s show time. It’s time to perform the biopsy.

[17] – [Perform biopsy!][Dr. Shah] – Okay, so, we want to do it right the first time to preserve the tissue. The more you mess around in there, the more bleeding you have, you know, the more your patient gets agitated, the more you get agitated, all this stuff happens. So you just really want to just know what you’re doing, you know, get in and get out, really. So do it right the first time. Make sure … one of the key things that I think is hardest about biopsy is making sure you have the proper depth. You don’t want to go too deep where you’re causing a huge hole and destroying tissue and leaving the patient vulnerable to infections and you don’t want to be so shallow that you can’t diagnose it and when you’re removing it you rip the tissue. Okay, so that’s something that comes with practice and knowing what you’re biopsying and know what you’re looking for. Ensure visibility. Well that seems kind of obvious, you’ve got to be able to see what you’re doing, right? And that’s where your assistant comes into play. You’ve got to have someone who’s suctioning where you’re cutting and suctioning the blood as you’re cutting so you can see what you’re doing, okay? And also sometimes, we don’t use the surgical suction tip but we have to have the assistant dab with gauze as you’re cutting, they dab with gauze. Handle the tissue carefully once you’ve actually removed the tissue. It needs to go straight in the 10% formalin container. Okay? The container should be labeled before you start with the patient’s name, the doctor’s name, the date, and the site. And by site, you know, and this is funny, I have to tell you. For site, some people put dental office, hospital, and that’s not what we mean. I mean buccal mucosa, anterior … and I’ve seen that, it still makes me laugh every time I see that. So, okay. So, we mean a specific location in the mouth, not where you’re located. Make sure the tissue is immersed in formalin, here’s another funny one. Someone will do this great stuff, they’ll do a biopsy, they’ll get it in the bottle, it’ll be stuck on the lid, they’ll close the lid, it’ll be crushed in the lid. Okay, and so, and then when we get the tissue, it’s dried, it’s dead, it’s no good. So, if you’re going to go to all that work, at least look at it, look at your product and turn the bottle over and make sure you see the tissue floating in the formalin, okay? It sounds kind of funny, but believe me, I have seen it. So make sure the tissue is immersed in formalin. Okay.

[18] – [Post-biopsy Steps][Dr. Shah] – Now what? It’s not over, we don’t just throw the tissue and the bottle, I’m done, I’m out of here. You really have to … that patient is your responsibility. And in fact, the worst part is this part where you have to control bleeding and make sure your patient is okay before you let them go. Okay? The biopsy can be quick; I mean I can do a biopsy from start to finish in less than five minutes. It’s the hemostasis and the issue afterwards that you have to deal with. Okay, so most of the time in a normal healthy patient, you can get hemostasis just with gauze pressure.

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You take the gauze, you hold it tight for about 5 to 10 minutes and the bleeding should stop. You should get a clot. Sometimes you have to hold it a little longer in a patient that has diabetes or has hypertension or some other medical issues. Most of the time, you know, hemostasis with gauze pressure works. There are times where you may have to use sutures, okay, especially, if you’ve gone deep or wide and you need to close the tissue. And then there are other times where you can use chemical cauterization with the silver nitrate stick and that’s another thing that’s very technique sensitive. It’s not … the silver nitrate stick is essentially burning the blood vessels and nerve endings and obviously you should be doing this when your patient is numb. You don’t want to do it when your patient is not numb because it will hurt, it will burn. Okay so with silver nitrate though, it’s only for pinpoint bleeding. If you’ve got this blood just gushing and spurting out, the silver nitrate won’t even stick or make it to the tissue. So it has to be like when you dab, you can see one point of bleeding, one vessel, or something like that, then you dab it dry and put the silver nitrate. Okay, and then once you’ve got hemostasis, you give post-op instructions to the patient. And then you schedule a follow-up. If you do a biopsy, you should schedule a follow-up. You are responsible for that patient or any complication to that patient. Okay? There have been times when biopsies are done and the patient has an issue and they have to go to the emergency room or I get a call or some issue happens. You are responsible so I’m very careful that I don’t do biopsies on Fridays, because I don’t want a call on the weekend. I don’t do biopsies before vacations or, you know, any big trips because, you know, you’re not around. You can’t follow the patient. So, you have to think about the follow-up appointment. Most of the time, we schedule a two-week follow-up. And can anyone think of why two weeks is a good amount of time to wait for the patient to come back? Think about this. What’s that? Why should you wait two weeks?

[Student]--[unintelligible]

[Dr. Shah]--Okay, so you’re sort of on track. We’re really waiting for healing and re-epithelialization, which takes about two weeks. Okay? So two weeks is a good amount of period to wait to see if there’s any signs of infection or to allow for healing, okay? So normally we wait two weeks. However, if you have a patient that let’s say I put my silk sutures in, I’ve got to see them in one week to remove those sutures, or let’s say you have a patient that you’re really worried about for the results or you’re really worried during the procedure they had a lot of bleeding or something else, I might call them earlier for like one week. I would probably never do a follow-up earlier than one week unless something went wrong during the biopsy procedure and I had to see them earlier. Okay? And then another reason at the school we like to do a two-week follow-up is to ensure, of course, when you do a biopsy when the patient comes back you want to give them the results of the biopsy, right? So you want to make sure that the lab that you sent it to has sent you a report so that you can give the results to the patient when they come back. So two weeks is a good amount of time to allow, you know, to send to the lab for pathologist to sign it out for it to come back. And here, you know, as I’m one of the pathologists, Dr. Phelan who’s going to be lecturing to you on Thursday who is the chair of the

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department and my boss, is the other oral pathologist, okay? And so for us, the turn around at the school is very fast. If you do a biopsy, in about two or three days the report will be there, you know, we work pretty fast and good like that. But some other places may take you longer, okay? So you want to allow time for biopsy results.

[19] – [Submitting the Biopsy][Dr. Shah] –Okay, then submitting the biopsy. Okay, so you’ve taken care of your patient, your patient has a follow-up appointment; the patient is leaving and gone, okay. Now, what do you do? You’ve got to submit the biopsy, so again, you want to make sure the bottle is labeled with the name of the patient, the date, and biopsy site. You want to fill out the form, there’s a form that goes with every biopsy bottle. And the form asks you, you know, what you think it was, where the site was and a bit about medical history. You want to put all important information and the specific site of the biopsy and you want to submit any clinical photos or x-rays. It’s really a good thing and you’ll note when you have a patient, now these cellphones and mobile phones have really good cameras. So you don’t have to buy those fancy clinical cameras and expensive cameras. But it’s really good practice to when you see something to take pictures of things. And it really helps if you send it to the pathologist to help make the diagnosis, okay? So, did someone have a question? I thought I saw somebody raise a hand back there … yea?

[Student]--[unintelligible]

[Dr. Shah]—Yes, absolutely. So the form also asks you whether it’s incisional or excisional and for the specific location. So, you know, what we ideally would like … it’s not enough to say just buccal mucosa. You should say right buccal mucosa. And we would even prefer if you say right anterior buccal mucosa instead of posterior. It’s really important especially if you have a patient with multiple lesions to know what was biopsied. And if you have multiple bottles, if you’re doing multiple biopsies, obviously you have to be very careful that you’re putting the right biopsy in the right bottle, okay? So there are definitely some important logistics for this. Okay. And then submit any clinical photos or x-rays.

[20] – [N/A][Dr. Shah] – Okay, so here’s a picture of a biopsy bottle, okay? This has got 10% formalin in it and you have these biohazard bags. These bottles should be placed inside of this bag, okay? And then these bags, these aren’t the bags and bottles we use at the lab actually. But the bags that we use have a pocket in the front and then they have a zipper component inside the bag. The pocket in the front is for the forms, okay? We keep the forms separate from the bottle. Many times the bottle opens or leaks so that the form doesn’t get ruined or smeared or destroyed or become illegible. And you should always, due to HIPPA, HIPPA’s privacy violations, you want to form the folds so that the confidential information is inside before you put it in the pocket, okay?

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[24] – [Punch Biopsy][Dr. Shah] – So. With that being said, I want to go over punch biopsy procedure. But before that, are there other questions? Okay, so let me go over the punch biopsy technique. So the punch is an actual instrument. Okay? It looks like a little cookie cutter, a round cookie cutter, to tell you the truth. And they have different colored handles. Okay? They are available in different diameters, two to five millimeters. Actually, there are bigger punches too. Some of them can be as big as 10 millimeters. And dermatologists tend to really like to use these and get these in different sizes. For oral biopsies we usually use the 4 or 5 millimeter punch. The 4 millimeter punch is good for most oral biopsies and we’re talking about the size of sample here when we say 4 millimeters. Okay, so a punch biopsy can be incisional or excisional, depending on the size of the lesion and the size of the punch, right? So for example, if your lesion is 3 millimeters and you’re using a 4 millimeter punch, then what kind of a biopsy is that going to be? Excisional. If your lesion is 10 millimeters and you’re using a 5 millimeter punch, then what kind of biopsy would that be? Incisional. So you see, it depends on the size of the lesion and the size of the punch so I can’t tell you whether the punch is incisional or excisional, okay?

[22] – [Punch Biopsy][Dr. Shah] – okay, this is what the instrument looks like. It has a plastic handle and then it has this metal thing over here, okay? And these are the ones we use. They have this green handle, okay? And as I said, they come in various sizes. We usually use the 4 or 5 millimeter punch and the size is written on the side here. Okay?

[23] – [N/A][Dr. Shah] – Alright. This is the procedure. Basically you have somebody retracting the area that you’re going to do the biopsy in. You’re going to put this thing… you sort of sink this thing in. You have to be very stable and you basically have to make several circles with the punch biopsy to get a nice round circle, okay? And this is tricky, I have to say that punch biopsy looks easy but it can be … it’s hard until you’ve done a few because of controlling depth. That’s the biggest issue. There’s no marks on this thing. There’s nothing to tell you how deep you’re going. You know, you could go all the way up to this plastic handle. I mean, there’s nothing to control the depth of this, okay? So you could be too shallow or you could be … you know, dig a deep hole and be too deep. So, it really comes with practice and that’s the trickiest part about the punch biopsy but once you’ve mastered that, this is a great, great, great technique. Okay and I’ll tell you what the advantages of this area. But, here you are, okay. There’s alleged lesion under this, maybe it’s part of a leukoplakia, I don’t know. Okay, and then the punch is here, it’s going to make a nice, round, 4 or 5 millimeter circle. And the person that’s doing this is going to slightly turn this a few circles so you get a nice, round circle. And it is so important that the person who is holding the tissue does a good job and that you’re stable. Because otherwise you can go too deep or your punch can go this way and now instead of a circle, you’re making some oval or some other bizarre shape as you go across the tongue. So it’s very important that, you know, you stay in one spot when you’re doing the punch

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biopsy. And again, depth is something that really takes practice. Most of the time, you just want to make sure you go through the epithelium and into the connective tissue so we try to get about 3 or 4 millimeters of depth. Okay?

[24] – [N/A][Dr. Shah] –This is the same lesion, okay? And this is the crcle that was made. So what you’re going to wind up getting is a nice circular outline of the tissue. Now there is a misconception I think many students think, especially when they do their fourth year rotation with us, as you all will, that when you take the punch out, magically the tissue is going to be in the punch and you’re through. That’s not the case. All you did was make a round hole. Now you have to pick up this hole, with the soft-tissue forceps, take a blade and cut this out. Okay? There are some skin … I think some dermatologists have some punches, I don’t know … there must be something special about them or maybe it’s because they’re going deeper, I don’t know … because the deeper you go, the more of a chunk of tissue does come out. So maybe with the skin biopsies, they’re able to get a big chunk that actually comes out with the punch. But for all oral biopsies that never happens, okay? You never get it coming out with the punch. You get this round hole here.

[25] – [N/A][Dr. Shah] –So then, this is what you do. You pick up the tissue with, you know, soft tissue forceps and then you undermine and cut the tissue. This is obviously a surgical scissor. I would prefer to actually use a scalpel. So you pick up one edge and you undermine it. And there’s a little bit of surgical technique involved in that when you’re removing this tissue you don’t want to go too shallow. There’s a tendency that you start going more and more shallow and, you know, your punch went deeper. And you want to get as much tissue as you can, so, that’s an important thing here too. Okay? So you can see we’re removing that.

[26] – [N/A][Dr. Shah] – And then this is what’s left behind here. You just have this … this is stating to clot. The tissue was removed from this area, okay? … No, there’s no suture in here. This is just the glare. I see what you’re referring to. That’s just a glare due to the photography. Okay.

[27] – [Punch Biopsy: Advantages][Dr. Shah] – Okay, so, any questions about the punch biopsy technique? I’m just going to go over the advantages and the disadvantages and I should be done in the next five minutes. Does anyone have any questions about the punch biopsy technique? Once you see it, it’s an interesting thing to see but the truth is, it’s going to look so easy. You’re going to say oh my god, that’s so easy. But the issue is, when you actually do it, controlling the depth and keeping position. It can be an issue. But once you’ve mastered that, it is great. So let me tell you why it is great. What are the advantages of punch biopsy? Well, once you’ve mastered the depth component, it’s a very easy technique, okay? Sutures are not required because when you use a punch biopsy you have a round hole. You can’t really suture that without causing a

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contraction scar and ripping tissue. Okay? So, it’s fast. It’s a very fast technique. You actually get very good healing. Keep in mind when you’re using a punch, you’re getting a clean, round hole. And the cleaner your margins, the less the bleeding and the better the healing. Okay? So that’s one of the prime advantages of punch biopsy. I’ll tell you that many times when I do a punch biopsy and I have the patient come back in two weeks, I don’t even know where the biopsy was. I don’t even know where it was done because the tissue heals so well. Okay? And I’d like to think it’s my expert biopsy technique as well but that’s a different story. Faster, better healing. More useful for lesions located on fixed, non-moveable tissue, okay? So you really want to make sure … it’s best if you use it on tissue that doesn’t move around because think about it. Because if the tissue is moving around, then you can’t control depth and position as easily. Okay? So, it’s more useful on fixed tissue on the gingiva, like the hard palate. However, if you have good retraction, you can use it on any kind of tissue, okay?

[28] – [Punch Biopsy: Disadvantages][Dr. Shah] –What are the disadvantages? The depth issue and then it’s difficult to use on freely moveable tissues, tissues that are moving around that you may not have good retraction for. Okay? So does everybody understand the advantages and disadvantages of the punch biopsies?

[28] – [More Punch Biopsies][Dr. Shah] –Here’s some more examples. There’s an example that’s being done again on the bottom of the tongue. And this is the actual tissue that’s bleeding with the round hole around it. That’s going to be removed. It’s kind of a rough leukoplakia here. Okay? Here’s another example of a punch biopsy being done. Okay? Any questions on the punch biopsy? Yeah?

[Student]—Since it’s hard to control depth, why don’t they put marks?

[Dr. Shah]—I don’t know, good question. Maybe we can develop that together. And go on shark tank or something, I don’t know. Yea, I need to come up with an invention so I can be rich. Okay.

[30] – [NYUCD Biopsies][Dr. Shah] – One thing about me that you may not know, this is probably TMI but you’re not going to believe this one, but I’m a poker player. I play, you know, Texas Hold ‘Em poker and I go to poker tournaments and my dream is to retire and join the World Series Poker tour so I need an invention. Let’s do that so I can go and play. Okay, last slide, guys. See? You didn’t see that one coming, right? The nerdy pathologist that plays Texas Hold ‘Em poker, right? But I’m able to fool a lot of people, you see? I have a great poker face. Okay. Last slide guys … last slide. Give me your attention for one more minute. Okay. NYUCD biopsies … this is just … I want you guys to know that we have an oral pathology lab that’s fully licensed and state certified on the 8th floor here, room 844. And this is where I spend a lot of my time and Dr. Phelan who’s going to be lecturing on Thursday spends time and we actually

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look at slides under the microscope there. So if you ever do a biopsy or you’re an assistant or you’re part of biopsy, which you will be in oral surgery, or something like that, the specimen goes to the 8th floor, room 844. There’s a drop box on the door for after hours. The specimen, when you’re carrying it in the school should always be in a plastic biohazard bag. Plastic biohazard bag. And then what happens after we sign for cases in the school, the report is sent to the clinic, GPD and put in the patient’s chart. Okay? And that is it. Alright, guys. Thursday, Dr. Phelan will be here to lecture about salivary gland diseases. See you next Monday.

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05: diagnostic procedures ii

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