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A digital manual for the early diagnosis of oral neoplasia

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Optimal treatment of diseases of the oral cavity depends on proper diagnosis and assessment of the extent of the lesion. The diagnosis is confirmed by biopsy, which is carried out under local anaesthesia after administration of the anaesthetic agent containing a vasoconstrictor. Topical application of anaesthetic agent prior to needle insertion does not result in any significant relief of discomfort, but may avoid anxiety. Antibiotic premedication may be considered in selected individuals, such as those with valvular heart disease, to prevent infective endocarditis.

The biopsy procedure should be properly planned and carried out under adequate lighting. The specific biopsy site and technique is determined on the basis of the clinical visual diagnosis and the location of the lesion. The points and aspects to be considered before embarking on a mucosal biopsy are listed in table 1Oliver RJ, Sloan P, Pemberton MN, (2004). Oral biopsies: methods and applications. Br Dent J. 2004 Mar 27;196(6):329-33; quiz 362. .

A provisional clinical diagnosis is especially important in guiding the technique. The guidelines for appropriate biopsy are summarized in table 2Oliver RJ, Sloan P, Pemberton MN, (2004). Oral biopsies: methods and applications. Br Dent J. 2004 Mar 27;196(6):329-33; quiz 362. . The biopsy should be taken from the clinically most suspicious area. The majority of mucosal biopsies are incisional. The punch biopsy technique is an alternative to the tradional incisional technique. Biopsy punches, number 15 Bard-Parker blade, atraumatic forceps and suture material are used for oral biopsies (figure 1). Biopsy punches are available in disposable or reusable forms and in different sizes. Disposable biopsy punches are lighter and easier to use than their metal counterparts. Most intraoral biopsies can be performed with a 3- or 5-mm punch without suturing. A 3-5 mm punch biopsy is sufficient for most mucocutaneous lesions. In small lesions an excision biopsy can be considered, which will provide both diagnosis and treatment in one session. If malignancy is suspected, biopsy should be of sufficient depth and have a surrounding margin to ensure adequate clearanceOliver RJ, Sloan P, Pemberton MN, (2004). Oral biopsies: methods and applications. Br Dent J. 2004 Mar 27;196(6):329-33; quiz 362. . Scalpel excision is usually done in an antero-posterior direction to minimize severing neurovascular structures. The biopsy specimens should be promptly placed in 10% buffered formalin fixative. Larger punch biopsies and scalpel excisions will require suturing for haemostasis. Care should be taken to avoid the use of nonresorbable suture material for submucosal closure. In large proliferative or ulcerative lesions, a punch biopsy/wedge can be taken from the edge of the lesion, avoiding necrotic areas (figures 2).


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Table 1: Points to consider prior to mucosal biopsy adapted from Oliver et al., 2004. Oliver RJ, Sloan P, Pemberton MN, (2004). Oral biopsies: methods and applications. Br Dent J. 2004 Mar 27;196(6):329-33; quiz 362. .
Table 2: Guidelines for an appropriate biopsy adapted from Oliver et al., 2004. Oliver RJ, Sloan P, Pemberton MN, (2004). Oral biopsies: methods and applications. Br Dent J. 2004 Mar 27;196(6):329-33; quiz 362. .
Figure 1: Instruments needed for biopsy procedure: A: reusable punch biopsy forceps, B: disposable punch forceps, C: needle holding forceps, D: thumb forceps, E: scissors, F: artery forceps, G: Bard-Parker knife.
Figures 2A and 2B: Incision biopsy procedure. Biopsy being taken from the edge of the lesion including a wedge of normal tissue.
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