|Year : 2021 | Volume
| Issue : 4 | Page : 227-231
Awareness of oral biopsy procedure among dentists: A web-based cross-sectional study
Shashi Keshwar1, Sonal Grover2, Deependra Prasad Sarraf3, Daya Shankar4
1 Department of Oral Pathology, College of Dental Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
2 Department of Oral Pathology and Microbiology, Christian Dental College, Ludhiana, Punjab, India
3 Department of Clinical Pharmacology and Therapeutics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
4 Primary Health Center, Saran, Bihar, India
|Date of Submission||30-Jul-2020|
|Date of Decision||07-Sep-2020|
|Date of Acceptance||28-Oct-2020|
|Date of Web Publication||27-May-2022|
Department of Oral Pathology, College of Dental Surgery, B.P. Koirala Institute of Health Sciences, Dharan
Source of Support: None, Conflict of Interest: None
Introduction: Various diagnostic procedures are available to reach a diagnosis in case of oral lesions/conditions. Biopsy is one of the important tools for confirmatory diagnosis. Therefore, the dentist should have adequate awareness regarding oral biopsy procedures. Objectives: The objective of the study was to determine the awareness of oral biopsy procedure among dentists in Haryana. Materials and Methods: It was a cross-sectional study conducted among dentists in Haryana, India, using a 16-item close-ended questionnaire. Google Forms was prepared via docs.google.com/forms, and the link was sent to the participants via social media platforms such as WhatsApp and Viber. The filled questionnaires were extracted from Google Forms and exported to Microsoft Excel 2016. Descriptive statistics such as frequency and percentage were calculated to present the data using the Statistical Package for the Social Sciences software, version 21. Results: Out of 68, only 35.3% and 50% of the dental surgeons were aware that the removal of tissue by laser or electrosurgery can introduce artifacts or tissue distortion and punch biopsy generally produces few artifacts within the biopsied sample, respectively. Among the respondents, 35.3% and 11.8% responded that formaldehyde and normal saline also can be used for fixation of the biopsy sample. Conclusion: Awareness of oral biopsy technique was not up to date among majority of the dentists. Eminent steps should be taken to increase the awareness of biopsy procedure among them.
Keywords: Awareness, dental surgeons, oral biopsy
|How to cite this article:|
Keshwar S, Grover S, Sarraf DP, Shankar D. Awareness of oral biopsy procedure among dentists: A web-based cross-sectional study. CHRISMED J Health Res 2021;8:227-31
|How to cite this URL:|
Keshwar S, Grover S, Sarraf DP, Shankar D. Awareness of oral biopsy procedure among dentists: A web-based cross-sectional study. CHRISMED J Health Res [serial online] 2021 [cited 2022 Sep 25];8:227-31. Available from: https://www.cjhr.org/text.asp?2021/8/4/227/346094
| Introduction|| |
For a definitive diagnosis of abnormal oral conditions, biopsy is a useful technique. It is the process of taking a sample of a lesion in living organism to perform histopathological analysis under a microscope to make a definite diagnosis., Biopsy must be performed carefully since any error may result in change in the histopathological diagnosis of the lesion. As microscopic analysis is a gold standard procedure to diagnose the lesions, so accurate identification of lesion would be only possible through histopathologic evaluation of biopsy sample.,, It also helps to determine the presence/absence of evidence of malignancy, provides information about the clinical course of the lesion, and provides prognostic data., The principal indications of oral biopsy are leukoplakia, erythroleukoplakia, pigmented lesions, ulcers known to be present for more than 2 weeks (excluding irritative factors), vesicular-ampullary diseases (lichen planus, pemphigus, and pemphigoid), soft-tissue masses (mucocele, fibrous hyperplasia, etc.), confirmation of systemic illnesses (amyloidosis and Sjogren's syndrome), and periapical lesions (granulomas and residual root cysts), among others.
During oral biopsy procedure, adequate and appropriate collection of the tissue sample is essential for accurate examination, diagnosis, and ultimately treatment. Biopsy must be performed carefully since any error may result in incorrect histopathological diagnosis of the lesion. Therefore, it is of utmost importance to understand what adequate and appropriate biopsy sample is. An appropriate biopsy contains tissue that is representative of the lesion. Basic knowledge and technical skills are required to perform a good oral biopsy. A good biopsy sample is influenced by proper site selection, the methods of administration of local anesthesia, the surgical method adopted to remove the tissue, the adequate size and the depth of the tissue from the representative site, and the subsequent fixation method. An accurate and relevant clinical description of the lesion can assist the pathologist in the diagnosis.
A lack of knowledge related to biopsy procedure and the management of biopsy specimens can cause artifacts which are false structures that change the normal morphological and cytological features of tissues. Insufficient biopsy sample and clinical data related to the patient and the biopsy impede the ability of pathologists to draw meaningful inferences from the sample. Therefore, the dentist should have adequate knowledge to undertake oral biopsy procedures. It has been observed that most of the biopsy specimens are inadequate and nonrepresentative of the oral lesion and the relevant clinical data are also missing. Therefore, this study was conducted to assess the awareness of oral biopsy procedure among dentists.
| Materials and Methods|| |
A web-based cross-sectional study was conducted among dentists in Haryana during February–March 2020. A semi-structured pro forma was prepared based on relevant literature., It consisted of sociodemographic data and 16 close-ended items on oral biopsy procedure with three options: “Yes,” “No,” and “Do not know.” The questionnaire was reviewed by the research team and the subject experts for confirming its relevance, simplicity, and internal consistency. It was pretested in 10% of the study population to establish validity and reliability. The pretested study sample was not used for the final data collection. The Cronbach's alpha reliability coefficient was 0.792 which was considered satisfactory for the study.
Google Forms was prepared via docs.google.com/forms, and the link was sent to the enrolled participants via social media platforms such as WhatsApp and Viber. Upon clicking on the link, it informed the participants of the study objective and stated that the study participation was purely voluntary. No incentive was given. Personal identifying information (e-mail address, phone number, name, etc.) were not collected to maintain the confidentiality of the participant.
The filled questionnaires were extracted from Google Forms and exported to Microsoft Excel 2016. Descriptive statistics such as frequency and percentage were calculated to analyze the data using the Statistical Package for the Social Sciences software, version 21 (IBM Corporation, Armonk, New York, USA).
| Results|| |
Google Forms was sent to 100 dental surgeons and 68 responded giving the response rate of 68%. Majority were male (76.5%), married (70.6%), and aged 30–45 years (67.6%). Most of them had completed a bachelor of dental surgery (61.8%) and had the experience of more than 5 years (70.6%) [Table 1].
Out of 68, 94.1% and 91.2% of the dental surgeons were aware of the definition of incisional and excisional biopsy, respectively; however, only 76.5% were responded that an appropriate incisional biopsy includes tissue sample from the most severely and significantly affected part of the lesion. Only 35.3% and 50% of the dental surgeons were aware that the removal of tissue by laser or electrosurgery can introduce artifacts or tissue distortion and punch biopsy generally produces few artifacts within the biopsied sample, respectively. Similarly, 64.7% of the participants were responded that toluidine blue or direct fluorescence visualization helps a dental surgeon highlight the most severe or significantly changed tissue for biopsy. Thirty-nine participants (57.3%) agreed that biopsies of the mucosa should be at least 3 mm in diameter and 2 mm depth. Out of 68, 55.9% of the participants were aware of the shrinking of biopsy specimens after formalin fixation [Table 2].
|Table 2: Awareness of oral biopsy procedure/technique among the participants (n=68)|
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Out of 68, 35.3 and 11.8% of the participants responded that formaldehyde and normal saline also can be used for fixation of biopsy sample [Figure 1].
|Figure 1: Response of participants regarding fixation of the biopsied tissue (n = 68)|
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| Discussion|| |
The oral biopsy procedure is a competence skill that is easily learned. The overall goal of the oral biopsy procedure is to obtain appropriate tissue that can be analyzed by the oral pathologist to reach a diagnosis. It is the responsibility of the dental surgeon performing the biopsy to obtain sufficient tissue and manage that tissue appropriately so that the sample arrives to the pathologist in a condition suitable for further processing and analysis. They should be able to take biopsies while they must be aware of a variety of factors influencing the histopathologic interpretation of an oral biopsy specimen to prevent the misidentification of the lesions. The study was conducted to assess the awareness of oral biopsy technique among dental surgeons. Our study revealed that despite the clinical experience of more than 5 years, most of the dental surgeons were not aware of many aspects of the oral biopsy procedure.
It was surprising to know that only one-third of the dental surgeons were aware of the fact that the removal of tissue by laser or electrosurgery can introduce artifacts or tissue distortion. Electrosurgery and laser generate heat that cause fulguration artifact that leads to changes in the epithelium and connective tissues.,, In fulguration artifact, epithelial cells appear separated from each other, and their nuclei appear a spindled, palisading shape and hyperchromatic.,, These changes are similar to the presence of epithelial dysplasia and mislead histopathology of the lesion. As margins are very important in case of malignancy/invasion or premalignancy, so these changes can alter the diagnosis as well as treatment modality.
Our study showed that only half of the dental surgeons were aware that punch biopsy generally produces few artifacts within the biopsied sample. While separating the tissue sample from the underlying base by scissors in punch biopsy, fragmentation of sample may occur. Hence, dental surgeons should be careful while separating tissue from the punch biopsy procedure.
In our study, one out of three dental surgeons was not aware of the fact that toluidine blue or direct fluorescence visualization helps a dental surgeon highlight the most severe or significantly changed tissue for biopsy. Toluidine blue is a metachromatic dye which has an affinity for nucleic acid, and it binds with high DNA and RNA contents of the cells. It is an easily available, economical, metachromatic dye known to bind DNA of dividing cells. In various studies, it has been mentioned to stain premalignant and malignant cells but not normal mucosa., Similarly, direct fluorescence technique recognizes the loss of normal tissue autofluorescence of dysplastic and neoplastic tissues; these changes are the result of a progression of histological and biochemical modifications. Hence, they can act as an adjunctive tool to check for early subtle clinical changes.
Nearly half of the participants did not know that biopsies of the oral mucosa should be at least 3 mm in diameter and 2 mm depth. Mucosal biopsy should be at least 3 mm in diameter and 2 mm in depth, while in case of oral premalignant lesion and squamous cell carcinoma, it should be deeper because of thickened epithelium and hyperkeratosis. The minimum recommended depth should be 4–5 mm in such cases. Our study revealed that nearly half of the participants were not aware of the shrinking of biopsy specimens after formalin fixation. A higher percentage of participants were aware of the shrinking of biopsy specimens after formalin fixation in a study done by Sunil et al.
Surprisingly, a lot of the dental surgeons believed that the specimen can be fixed in formaldehyde and normal saline and similar findings were reported in other studies.,, These results signify that that most of the dental surgeons were not aware of the importance of preservation and fixation of biopsy specimens. Selection of the right preservative solution is one of the important factors in preserving tissue architecture. Preservation of biopsy specimens in improper fixative might lead to an inaccurate histological diagnosis which ultimately may require repeated biopsy of the same lesion. The biopsy specimen should immediately be placed in a fixating solution because tissue autolysis takes place rapidly after resection and taking the specimen due to the disruption of blood supply to the tissue specimen. The best and most commonly used fixative is 10% neutral buffered formalin. Other solutions such as water, saline solution, and alcohol are not suitable alternatives for formalin, as they cause severe and destructive changes in the tissue.
One out of three dental surgeons responded that it is not mandatory to label the specimen container with the patient's name, age, date of biopsy, and the site of the biopsy. The biopsy specimen should be accompanied with complete patient history and particulars (name, age, gender, and medical history including the drugs used, use of alcohol, and smoking), data about the lesion (clinical appearance, presence of other lesions, the results of other evaluations, the type of the biopsy, and clinical diagnoses), and also the name and address of the dentist in charge. It is very useful to include a diagram on the oral pathology biopsy requisition form to show the location and size of the specimen and area of sampling. Other details, including the shape and color of the lesion, its texture, and radiographs (if any), should also be provided. Providing such data will contribute to a more thorough and comprehensive interpretation of the specimen. Providing clinical differential diagnosis is very valuable for pathologists because it contains the dentist's viewpoint about the lesion. Lack of clinical data or incorrect differential diagnoses will result in ordering unnecessary tests or use of a wide range of immunohistochemical staining techniques. To a large extent, this could be attributed to the lack of practical and theoretical training in biopsy technique; these dentists have received during their dental training. This emphasizes that during undergraduate and postgraduate training, higher levels of importance to be placed on this aspect in the dental curriculum. The dentists who have been taught how to perform biopsy and had practical experience of the same during their undergraduate/postgraduate course are more likely to undertake biopsies later in their practice. Our study has some limitations. Besides a lower response rate, it was conducted in a single region. Therefore, the findings could not be generalized. The response may not be the actual reflection of their awareness.
| Conclusion|| |
Our study findings revealed that awareness of oral biopsy technique was not up to date among majority of the dental surgeons. Practical exercises on oral biopsy procedure should be emphasized during undergraduate dental education. Continued dental education and workshop on the oral biopsy procedure are required to make the dental surgeons more competent and confident in performing oral biopsy.
We would like to extend our gratitude toward the participants for their participation in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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