Biopsy Techniques

B i o p s y Te c h n i q u e s
and Diagnoses &

Tre a t m e n t o f
Mucocutaneous
Lesions
a,b, b
Michael H. Chan, DDS *, Joshua C. Wolf, DDS
KEYWORDS
Biopsy Mucocutaneous Vesiculobullous
Immune-based lesions Treatment
Oral mucosal lesions are commonly encountered in clinical practice. A study conduct-
ed in the United States reported that they occurred in approximately 27.9% of patients
aged 17 years and older1 and in 10.3% of children aged 2 to 17 years.2 The diagnosis
and treatment of mucosal diseases should be an integral part of the general prac-
titioner’s practice. According to an American Dental (ADA) survey conducted in
2007, of 315,210 biopsies, 138,810 (44%) were performed by a general practictioner.3
Understanding of the fundamentals of diagnosing mucocutaneous lesions requires
a sound knowledge of its origin and clinical course, and of biopsy methods using
contemporary diagnostic tools and techniques.
APPROACH TO LESIONS
A through systematic approach should be sought for every oral lesion, with the chief
complaint as the starting point of the investigation.
Health History
A complete medical history should be obtained for all patients before performing an
examination. An existing systemic condition can contribute to the cause of the lesion.
The authors have nothing to disclose.

a
Oral & Maxillofacial Surgery/Dental Service, Department of Veterans Affairs, New York Harbor
Healthcare Systems (Brooklyn Campus), 800 Poly Place (Bk-160), Brooklyn, NY 11209, USA
b
Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb
Avenue, Box 187, Brooklyn, NY 11201, USA
* Corresponding author. Oral & Maxillofacial Surgery/Dental Service, Department of Veterans
Affairs, New York Harbor Healthcare Systems (Brooklyn Campus), 800 Poly Place (Bk-160),
Brooklyn, NY 11209.
E-mail address: Michael.chan2@va.gov
Dent Clin N Am 56 (2012) 43–73

doi:10.1016/j.cden.2011.09.004 dental.theclinics.com
0011-8532/12/$ – see front matter Published by Elsevier Inc.
Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
44 Chan & Wolf
For instance, does the patient have lupus erythematosus, a sexually transmitted
disease, tuberculosis, or an immune-compromised condition [eg, HIV, AIDS,
leukemia], is the patient currently undergoing chemotherapy treatment, or has the
patient been prescribed any new medications by another provider that may be
causing a lichenoid reaction. Social history is particularly important if the patient has
a smoking, alcohol, or beetle quid habit, because these are well-known carcinogens.
Lesion History
The focus of the examination should then shift to the history of the lesion. The usual
initial questions are how long has the lesion been present, was it noticed by the patient
or during a routine oral screening, has the lesion changed in size, and is any associ-
ated paresthesia present. A benign lesion usually has a slower growth as opposed
to one that is malignant, which is more aggressive and has associated paresthesia.
Patients should be asked if any associated symptoms are present, such as pain, fever,
headaches, chills, or lymphadenopathy, and whether the characteristics of the lesion
changed (eg, did the ulcer start as crops of vesicles or was it always an ulcer). A
change in its features would highly suggest vesiculobullous disease or a disease of
viral origin. Furthermore, did any recent memorable events lead up to discovery of
the lesion (eg, trauma, local irritant, exposure to allergens). For instance, if the lesion
was caused by a sharp cup rubbing against the tongue, it would be best remedied by
smoothing the offending origin, with an appropriate follow-up to determine if the lesion
needs further investigation.
Clinical Examination
An understanding of the normal anatomy will help the general practitioner differentiate
between normal mucosa and an oral lesion. The general practitioner should be able to
describe the presentation of the lesion in terms of location, size, shape, growth
pattern, the sharpness of lesion borders, mobility, and consistency of the lesion on
palpation. The general practitioner must also be aware of the possibility of two or
more different lesions or one lesion with different presentation. A head and neck
examination with lymph node inspection is mandatory before any oral biopsy. Lymph-
adenopathy can result from the surgical biopsy itself and can be confusing if TMN
cancer staging were deemed necessary in the future.
With the information gathered during the history and physical examination, the
general practitioner can develop a working differential diagnosis. Developing a differ-
ential diagnosis helps the general practitioner in using certain biopsy techniques and
diagnostic tools that can facilitate a correct diagnosis. This article addresses mucocu-
taneous lesions that will be encountered in the dental practice.
MUCOCUTANEOUS DISEASES
Primary Herpetic Gingivostomatitis and Recurrent Herpes Lesions (Labialis
or Stomatitis)
Two strains of herpes simplex viruses (HSV) exist. HSV-1 is usually responsible for
perioral/orofacial infections and HSV-2 for genital infections. Two clinical manifesta-
tions of HSV-1 can occur: primary herpetic gingivostomatitis and recurrent herpetic-
lesion labialis (lips) or stomatitis (intraoral). The route of transmission is through
infected saliva, active perioral lesions, and sores on skin. Transmission easily occurs
through intimate contact, kissing, sharing eating utensils, and toothbrushes. Only 1%
of the population that gets the primary infection develops full-blown symptoms. This
condition is called primary herpetic gingivostomatitis. The other 60% to 90% of chil-
dren and young adults seroconvert to HSV antibodies without any clinical symptoms.4

Diagnoses & Treatment of Mucocutaneous Lesions 45
After a period of incubation (usually 7 days), patients can experience a variety of symp-
toms, including headaches, irritability, muscle soreness (myalgia), pain on swallowing,
fever, and painful lymphadenopathy. Crops of vesicles appear and rupture within 24
hours and then coalesce to form ulcers in the oral mucosa involving the gingiva (kerati-
nized and nonkeratinized), tongue, and lips (Fig. 1). New lesions can continue to
develop up to 7 more days and usually heal without scarring within 3 weeks.
After the primary HSV infection, the virus lays dormant in a regional nerve ganglion
(ie, trigeminal ganglion) until a stimulus triggers it to cause a secondary or recurrent
infection. This stimulus may be sunlight (sun sores), physical or emotional stress,
hormonal changes (menstrual cycle), preceding upper respiratory infection (fever
blister or cold sores), or suppression of the immune system (caused by HIV, AIDS,
or current chemotherapy). The two clinical manifestations include the labialis and
stomatitis. Herpes labialis is the more common of the two recurrent HSV infections.
The clinical course starts with a tingling or itching sensation (prodrome phase) after
which these crops of vesicles will coalesce and rupture within 48 hours. It proceeds
to ulcerate, leaving behind a crusted brownish lesion on the lip (Fig. 2). The intraoral
component (stomatitis) appears on keratinized gingiva (ie, hard palate or attached
gingiva) and the tongue. The commonest region is the posterior hard palate over
the greater palatine foramen (Fig. 3).5 Unlike herpes labialis, these intraoral herpes
seldom form vesicles, and proceed to ulcerate, leaving behind an erythematous
macular base. Both clinical forms heal without scarring within 7 to 10 days.
Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis (RAS) affects 20% of the population worldwide
between ages 10 and 30 years, with 50% being college students.4 It occurs more
common in women than men. The clinical signs and symptoms can include a tingling
Fig. 1. Acute primary herpetic gingivostomatitis. Multiple shallow punctate lesions on both
keratinizing and gland-bearing mucosa. (A) Lower lip, (B) gingiva, and (C) tongue. (From
Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd
edition. Mosby; 2004. p. 210; with permission.)

46 Chan & Wolf
Fig. 2. Recurrent herpes labialis. (A) Early stages consisting of fluid-filled viral vesicles. (B)
Late stage showing brownish crusted lesions. (From Sapp JP, Eversole LR, Wysocki GP.
Contemporary oral and maxillofacial pathology. 2nd edition. Mosby; 2004. p. 211; with
permission.)
or burning sensation, a well-delineated white ulcer with erythematous halo, and the
absence of a vesicular stage. Although the cause of RAS is still unknown, local and
systemic predisposing factors can contribute to its development. Local injuries to
the oral mucosa, such as from trauma or tobacco smoke, can be offending agents.
Systemic diseases, such as Behçet’s disease, MAGIC (mouth and genital ulcers
with inflamed cartilage) syndrome, PFAPA (periodic fever, aphthous-stomatitis, phar-
yngitis, adenitis) syndrome, cyclic neutropenia, HIV disease, and hematologic defi-
ciencies (eg, iron, folic acid, vitamin B12), could produce aphthous-like ulcerations in
the oral cavity.6
Three forms of RAS exist: (1) minor (canker sore), (2) major (Sutton disease, peria-
denitis mucosa necrotica recurrens), and (3) herpetiform ulcerations.6
The minor form (canker sore) is the most common form of RASs, accounting for
80% of patients. Typically, these lesions are less than 5 mm in diameter, round, or
oval-shaped with a grayish-white pseudomembrane and an erythematous halo.
They appear on nonkeratinized surfaces on labial and buccal mucosa, the floor of
the mouth, movable gingiva, the palate, and the dorsum of tongue (Fig. 4). The lesions
heal in 10 to 14 days uneventfully.
The major form affects 10% of the patients with RAS. The lesions are greater than
1.0 cm in diameter. They tend to locate on the lips, soft palate, and fauces (Fig. 5).
They last longer than the minor form and heal without scarring in 6 weeks. Major
RAS has its onset after puberty and can persist for 20 years or more.7
Fig. 3. Recurrent intraoral herpes. (A) Common intraoral site on posterior palate over
greater palatine foramina. (B) Occasionally encountered gingival lesions. (From Sapp JP,
Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd edition.
Mosby; 2004. p. 211; with permission.)

Fig. 4. Minor RAS. Lesions are shallow crateriform ulcers with a whitish-yellow base and an
erythematous halo. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillo-
facial pathology. 2nd edition. Mosby; 2004. p. 254; with permission.)
Herpetiform ulcerations present in 1% to 10% of patients with RAS. The lesions are
usually 2 to 3 mm in diameter, with 100 ulcers appearing at a time. They can congre-
gate into large lesions or diffuse throughout the oral cavity (Fig. 6).
Lichen Planus
Lichen planus (LP) is a chronic mucocutaneous disease of unknown origin. It generally
develops in patients between 40 and 70 years old, with a predilection for women (2:1).8 It
affects the oral mucosa, tongue, and skin. The skin lesions occur on the flexor surface of
the extremities with the four Ps (purple, pruritic, polygonal papules) (Fig. 7).9 Although
oral LP is prevalent in 2% of the population, skin lesions show along side with oral
lesions in 12% to 14% of the time.10 Oral LP can be classified into two types: reticular
(reticular, plaque-like) and erosive (atrophic, bullous, ulcerative) (Fig. 8).11 Reticular LP
is much more common than the erosive form, with a higher predilection for buccal
mucosa (bilateral 85% of the time), the dorsum surface of tongue, and attached gingiva.
The reticular form is asymptomatic. It gets its name because of the interlacing white
lines patterns known as Wickham striae (Fig. 9). These lesions wax and wane over
weeks and months. However, the erosive type can have a long painful clinical course.
Clinically, atrophic and erythematous areas are present, with central ulceration of
Fig. 5. Major RAS. Large shallow ulcers of labial mucosa (A) and lateral soft palate (B). Lesions
are painful and exhibit characteristic erythematous halo. (From Sapp JP, Eversole LR, Wysocki GP.
permission.)

48 Chan & Wolf
Fig. 6. Herpetiform (aphthous) ulcers. Clusters of small shallow aphthous ulcers of the labial
mucosa that resemble lesions of a herpes simplex infection. (From Sapp JP, Eversole LR,
Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd edition. Mosby; 2004.
p. 256; with permission.)
Fig. 7. LP. Papular skin lesions distributed in a linear pattern on the flexor surface of the
wrist. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial
pathology. 2nd edition. Mosby; 2004. p. 259; with permission.)
Fig. 8. LP. (A) Clinical appearance of the symptomatic erosive form of the disease on the
buccal mucosa, exhibiting a large area of erosion against an erythematous background.
(B) Plaque form of LP on the buccal mucosa. (From Sapp JP, Eversole LR, Wysocki GP. Contem-
porary oral and maxillofacial pathology. 2nd edition. Mosby; 2004. p. 258; with permission.)

Fig. 9. LP. Clinical appearance of the lacework pattern of the reticular form of the disease.
(From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd
varying degrees. The periphery is usually bordered by fine, white, radiating striae.
Sometimes the atrophy and ulceration are confined to the gingival mucosa, called des-
quamative gingivitis. If the erosive component is severe, epithelial separation from the
underlying connective tissue may occur, followed by minor trauma. This rare presenta-
tion is known as bullous lichen planus. Controversy exists over the actual malignant
transformation of erosive LP to squamous cell carcinoma (1.5%–2.5%).4
Mucous Membrane Pemphigoid

Mucous membrane pemphigoid (MMP) is an autoimmune disease that affects many
mucosal surfaces, including oral, ocular, nasal, esophageal, laryngeal, pharyngeal,
genital, and skin. Oral and ocular surfaces remain the most common sites. The
mean age of onset is older than 40 years, with predilection for women (2:1). Oral mani-
festations include vesiculobullous eruptions, desquamative gingivitis, and ulcerations
(Fig. 10). With gingiva being the most common site, these lesions begin as painful
fluid-filled blisters that then slough off, leaving behind a denuded ulcerative base
(Fig. 11). Epithelial sloughing with digital pressure or perilesional manipulation indi-
cates a positive Nikolsky sign, and resembles the skin falling off of a sour grape. Heal-
ing may take days to weeks, and scarring is usually not seen. The ocular component
Fig. 10. MMP. Gingiva containing patchy areas of erythema and atrophy with loss of normal
stippling. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial

50 Chan & Wolf
Fig. 11. MMP. (A) Gingiva exhibits loss of adhesion of epithelium to connective tissue. (B)
Multiple diffuse areas of superficial erosions (white) against an erythematous background
caused by mechanical forces of a denture on the fragile atrophic epithelium. (From Sapp
JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd edition.
can progress to scarring, resulting in fusion of the eyelid and conjunctiva (symble-
pharon) (11%–61%). Poorly treated or untreated ocular lesions can ultimately lead
to blindness.12–14 Lesions on the laryngeal mucosa can also lead to severe scarring,
resulting in stricture. Skin involvement is only a small component and is manifested
in 0% to 11% of cases.12–14 A proper referral to the ophthalmology; otolaryngology;
urology; or dermatology department is necessary for proper care.
Pemphigus Vulgaris
Pemphigus vulgaris (PV) is an autoimmune disease involving the skin and mucous
membrane that can be life-threatening. It affects a wide age range, from children to
adults, with a predilection for people in their fourth to sixth decade. The condition is
seen more often in individuals of Ashkenazi Jewish or Mediterranean descent. The
overall incident is 0.1 to 0.5 patients per 100,000 population per year.15
The oral component of PV begins as a bulla formation, which will quickly rupture and
leave behind a painful ulcerative base. The oral cavity is commonly the first site for PV
development and can be found in the buccal mucosa, palatal mucosa, and lips
(Fig. 12). Lesions confined in the oral cavity are not life-threatening, whereas cuta-
neous involvement is considerably more severe and fatal. Death is caused by septi-
cemia or a fluid and electrolyte imbalance. Other mucous membranes may be
affected, including the conjunctiva, nasal mucosa, pharynx, larynx, esophagus, and
genital mucosa. Referral to a specialist is necessary for appropriate treatment. The
clinical course has a rapid onset with a variable and unpredictable resolution.
Erythema Multiforme
Erythema multiforme (EM) is an acute immune-based inflammatory disease that affect
both mucous membrane and skin (target lesion). The mucosal lesions include ocular,
oral, and genital surfaces. EM seems to be a disease of children and young adults
between 20 and 30 years of age. The origin is thought to be triggered by precipitating
factors, such as infection, drugs, gastrointestinal conditions, malignancies, radiation
therapy, or vaccination, with an explosive onset.
EM has two clinical forms, EM minor and EM major. EM minor more often affects the
skin than the oral cavity (25%). The minor form can affect no more than one mucosal
surface, with skin involvement. The minor form has a prodrome phase characterized
by symptoms such as headache, fever, and malaise, followed by the formation of
a papule or bulla that collapses to form “target lesions” (Fig. 13). The oral presentation

Fig. 12. PV. (A) Multiple erosive lesions of the soft palate. (B) Erosive lesions of the posterior
buccal mucosa. (C) Blister formation (arrow) on normal-appearing gingiva after the move-
ment of mirror handle under pressure, indicating positive Nikolsky sign. (D) Dry, crusted
lesions on the skin. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillo-
facial pathology. 2nd edition. Mosby; 2004. p. 267; with permission.)
of EM minor has the same characteristics, ranging from similar to aphthous-like ulcers
to diffused erythematous erosion spots. The condition is self-limiting, with resolution in
2 to 3 weeks. A correlation of oral and cutaneous findings is needed to make the diag-
nosis. Tissue biopsy is not necessary to rule out this lesion; however, ruling out other
vesiculobullous diseases may be helpful.
EM major is characterized by involvement of two or more mucosal surfaces and skin
surfaces. The bulla develops and later pops, leaving a dark-red crusted lesion. EM
major has two forms: (1) Stevens-Johnson syndrome and toxic epidermal necrolysis
(TEN), or Lyell syndrome. The Stevens-Johnson syndrome is characterized by an
Fig. 13. EM. Skin of a young patient exhibiting characteristic “target” lesions. (From Sapp JP,
Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd edition.

52 Chan & Wolf
extensive oral lesion commonly found in keratinized and nonkeratinized gingiva and
bloody crusted lips (Figs. 14 and 15). Extraoral involvement includes ocular, esopha-
geal, and genital surfaces. Scarring and partial blindness can result from ocular
involvement. The mortality rate is 5% for Stevens-Johnsons syndrome. TEN is an
even more extreme form of EM major, with a mortality rate as high as 30% to
35%.5 The skin lesions are extensive and can resemble severe burns. Death occurs
because of substantial loss of electrolytes and fluids, and widespread infection.
Lupus Erythematosus
Lupus erythematosus is a chronic inflammatory disease that targets the oral and cuta-
neous surfaces, and the end organs associated with circulating autoantibodies. Its
origin is not fully understood, but it is thought to be caused by environmental, genetic,
and hormonal factors. Three forms of lupus erythematosus exist: (1) discoid lupus
erythematosus (DLE), (2) subacute cutaneous lupus erythematosus (SCLE), and (3)
systemic lupus erythematosus (SLE). DLE is the mildest form and is confined to the
cutaneous surface of the face; the scalp, with associated hair loss (alopecia); the
ears, and occasionally the oral mucosa. The intermediate form is SCLE, which affects
the head and neck and upper trunk, and extensor surfaces of the arm. Myalgia,
arthralgia, fatigue, and malaise are common symptoms. The most severe and com-
monest form is SLE. These circulating autoantibodies target end organs, resulting in
inflammation to the heart (pericarditis), lungs (pleurisy or pleural effusion), kidneys
(lupus nephritis), and vasculature (vasculitis). Bone marrow with an anemia profile is
present. The classic “butterfly rash” is found across the malar region (Fig. 16). The
disease affects primarily women (9:1) during childbearing years, with an oral manifes-
tation around 21%.5
The oral manifestation of lupus can have a variety of appearances, ranging from leu-
koplakia, to erythematous erosions, to chronic ulcerations. The leukoplakia lesions
can be longstanding in the oral cavity without any symptoms. Patients will complain
of burning mouth symptoms associated with the erythema and ulcerative conditions
(Fig. 17).
BIOPSY/BIOPSY TECHNIQUES
Understanding the role of biopsy for oral mucocutaneous lesion will help general prac-
titioners not only make a correct definitive diagnosis but also understand how to
perform a biopsy that will be most beneficial for the pathologist (Fig. 18).
Fig. 14. Erythema multiforme. (A) Erosive lesions of the labial mucosa and gingiva. (B)
Diffuse area of superficial sloughing and focal erosions of the palate. (From Sapp JP,
Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd edition. Mosby;
2004. p. 272; with permission.)

Fig. 15. Erythema multiforme. Acute form of EM major (Stevens-Johnson syndrome [SJS]) in
2-year-old male, exhibiting characteristic “target” lesions of the skin and hemorrhagic
encrustations of the lips. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and
maxillofacial pathology. 2nd edition. Mosby; 2004. p. 273; with permission.)
Indications
A biopsy involves obtaining tissue for histologic examination and definitive diagnosis.
A biopsy is indicated for the following reasons:
To rule out malignancy for any lip or oral lesion that persists for longer than 2 weeks
after the exclusion of local irritants. If the lesion is a longstanding ulcer, some
adjacent clinically normal epithelium should be included in the biopsy for
comparison, and because the center of ulcers are usually necrotic tissue and
have no diagnostic value.
To evaluate any mucosa showing erythroplakia or leukoplakia, which may indicate
a precancerous lesion. Lesions with erythroplakia or that are speckled with
different appearances are now known to have a higher incidence of dysplasia
Fig. 16. Lupus erythematosus. Vasculitis and skin rash over malar areas of face (“butterfly
rash”) that intensify with exposure to sunlight are common in most forms of the disease.
(From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology.
2nd edition. Mosby; 2004. p. 275; with permission.)

54 Chan & Wolf
Fig. 17. Lupus erythematosus (LE). Patient with oral mucosal lesions of the tongue (A) and
palate, consisting of diffuse and annular leukoplakic lesions, erythematous areas, and
chronic ulcerations (B). Intraoral lesions are most frequently found in patients with the
discoid form of LE but may be present to a lesser degree in all forms of the disease.
(From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology.
2nd edition. Mosby; 2004. p. 275; with permission.)
and should be the areas of biopsy. Multiple biopsies may be needed for large or
multiple lesions.
To confirm a clinical diagnosis of LP or blistering lesions like pemphigus or pemphi-
goid. In a suspected LP lesion, sampling should be from a nonerosive area of the
lesion, because the erosive areas will show nonspecific inflammatory changes
and will not aid in the diagnosis. In the vesiculobullous lesions, the biopsy site
should be adjacent to the bulla, where the epithelium is still intact. For these
lesions, the laboratory should receive a fresh specimen in addition to a formalin
one to allow for direct immunofluorescence.
If viral
etiology is
Despite all local irritants removed
suspected,
2-3 weeks earlier
perform
viral workup
Biopsy Technique
Long standing Bulla (with epithelium)

Ulcer R/O MMP, R/O E.M
>1 cm, multiple Small Ulcer (<1.0 cm)
R/O Pemphigus
lesions,
suspected
malignancy
Take lesion with

Incisional (+,- ) Brush Excisional (+,-) Brush intact epithelium
Biopsy Biopsy Biopsy Biopsy (2 specimens)
Formalin Michel’s
solution
Immunoflourescence
study
Fig. 18. Biopsy technique for oral mucocutaneous lesion.

Contraindications
Contraindications to biopsy exist in several instances:
In seriously ill patients, in patients with systemic disorder that may worsen, or when
secondary complications may develop postoperatively
In areas that are difficult to access, where the surgery is difficult or hazardous
because of the risk of injuring vital structures
In cases of suspected vascular lesions or unstable coagulopathy, when an incision-
al biopsy should never be performed because of the risk of massive and persis-
tent bleeding
When the clinical diagnosis is a normal anatomic variant, such as physiologic
gingival pigmentation, geographic tongue, linea alba, and fordyce granules.
Once the decision to biopsy is made, the general practitioner must decide which
type to perform. This article describes the techniques of exfoliative cytology (brush
biopsy), incisional biopsy, and excisional biopsy.
Oral transepithelial brush biopsy with computer-assisted analysis (TBBCA) was
introduced in 1999 (patented by OralCDx, CDx Laboratories, Suffern, NY, USA) to
allow clinicians to differentiate between precancerous and cancerous cells. This
procedure is not designed to identify processes other than epithelial dysplasia and
squamous cell carcinoma, and therefore if candidiasis or LP is suspected, other
biopsy modalities should be used. The OralCDx kit contains a glass slide, slide holder,
fixative package (95% ethanol alcohol and 5% carbowax), and a brush instrument. No
topical anesthesia is needed because this may interfere with cell collection. The clini-
cian must rotate the brush until mild bleeding is seen. The collected sample must be
placed on the glass slide and the fixative material immediately poured on the spec-
imen. The slide should dry for 15 to 20 minutes and then placed in the slide holder.
The clinician should then place the slide in the prepaid Priority Mail package with
the patient information sheet filled out and sent to Oral Scan Laboratory.16 The current
ADA Current Procedure Terminology (CPT) code for brush biopsy is D7288 and the
procedure is compensated by the usual dental insurance plans.
Four results from the OralCDx biopsy are possible. Negative results indicate no
epithelial disease and require no further treatment. Atypical results indicate abnormal
epithelial structure of uncertain diagnosis, and positive results indicate definitive
dysplasia. Both of these results warrant a scalpel biopsy to confirm a definitive tissue
diagnosis. Inadequate results indicate an incomplete transepithelial biopsy, and
rebiopsy of the lesion is required. The general practitioner may elect to either reper-
form the brush biopsy or perform a conventional scalpel biopsy.
Initial data from brush biopsies performed in 1999 showed promising results, with
a sensitivity of 96% and specificity of 97%. The procedure has a false-negative rate
of 4% and a false-positive rate of 10%.17 An updated study conducted in Germany
found the sensitivity and specificity of OralCDx to be 52% and 29%, respectively.18
This is much lower than the initial report given by Sciubba.17 The brush biopsy can
also be used as a follow-up tool and for patients who are unable or refuse to undergo
other traditional biopsy methods.
Incisional biopsy is reserved for lesions that are generally large (>1.0 cm), multiple,
diffuse, or suspected malignancies. The biopsy sample is meant to serve as a repre-
sentative portion of the lesion and part of healthy tissue. An incisional biopsy should
be narrow and deep rather than broad and shallow. The depth of the incision should
be three times the width.19 As a general rule, the biopsy sample of an ulcerative
lesion should include representative abnormal tissue with 2 to 3 mm of normal

56 Chan & Wolf
tissue (Fig. 19). This specimen will give the pathologist a representative lesion for
microscopic examination. Lesions that contain areas of erythroplakia and leukoplakia
should have multiple samples removed; if this is not possible, then areas with erythro-
plakia should be prioritized, because these have the most active cellular activity
(Fig. 20).
Excisional biopsy is reserved for lesions that can be cured through complete
removal, that are smaller than 1 cm, that are presumed clinically benign, and are surgi-
cally accessible. Removal of the lesion must include 2 to 3 mm of normal tissue (Fig. 21).
Ultimately, the differential diagnosis of a lesion dictates how a biopsy should be
taken. For example, if an immune-based vesicle or ulcer is suspected, such as LP,
pemphigoids, pemphigus, or SLE, then the biopsy should include clinically involved
areas with some adjacent normal-appearing tissue and suspected lesion while avoid-
ing ulcerated or ruptured vesicular areas, because this will yield a nonspecific inflam-
matory response.20 Certain immune-based diseases will require a second biopsy so
that an immunofluorescence study can performed to serve as a diagnostic adjunct.
TYPES OF INSTRUMENTS
The scalpel biopsy remains the gold standard for establishing a definitive diagnosis.
The size, shape, and depth of the biopsy can be tailored based on the differential diag-
nosis. Punch and laser biopsies are an alternatives to the scalpel technique (Box 1).
Punch biopsy is a useful alternative to traditional scalpel biopsy. This technique can
be used to diagnose multiple mucocutaneous lesions. The Keyes biopsy punches
come in sizes ranging from 1.0 to 12.0 cm in 0.5-cm increments.21 The advantages
of this technique are its low surgical morbidity, that it generally requires no sutures,
and that it can be used in any accessible oral mucosal region. The disadvantage is
the limitation of depth that the punch can reach (the epithelial or superficial mesen-
chymal layer). The ideal surgical sites are the labial, buccal mucosa, and tongue
surfaces. This technique requires the biopsy blade to be placed over the specimen
and the handle rotated gently with the index and thumb until the external bevel of the
blade is no longer visible. Counterpressure is needed to provide adequate pressure
during the procedure. The blade should reach to the depth of connective tissue layer.
If a base layer is still left, it can be released by a conventional No. 15 scalpel blade.
Fig. 19. (A) Illustration showing desirability of obtaining deep specimen rather than broad
and shallow specimen when incisional biopsy is performed. If malignant cells are present
only at base of lesion, broad and shallow biopsy might not obtain these diagnostic cells.
(B) Illustration showing desirability of obtaining incisional biopsy at margin of soft tissue
lesion. Junction of lesion with normal tissue frequently provides pathologist with more diag-
nostic information than if biopsy were taken only from center of lesion. This is particularly
important when a biopsy of an ulcer is performed. (From Hupp JR, Ellis III E, Tucker MR.
Contemporary oral and maxillofacial surgery. 5th edition. St Louis: CV Mosby; 2008. p. 436;
with permission.)

Fig. 20. Illustration demonstrating desirability of obtaining more than one incisional biopsy
if characteristics of lesion differ from one area to another. (A) Frequently, one area of lesion
appears histologically different from another. (B) When obtaining biopsy on buccal or labial
mucosa, incision is usually carried to depth of musculature. (From Hupp JR, Ellis III E,
Tucker MR. Contemporary oral and maxillofacial surgery. 5th edition. St Louis: CV Mosby;
Laser is an acronym for “Light Amplification by Stimulated Emission of Radiation.”

Any laser device can produce light energy through a power source and an active
medium. The light energy produced by the laser emits and produces light at different
wavelengths. It is the spectrum of wavelengths that determine the absorption into the
various bodily tissues. Wavelength at the lower spectrum tends to attract soft tissue
whereas mid and far infrared range attract water and hydroxyapatite crystals (eg, teeth
and bones). For example, laser light is generated by an internal power source and then
through an active mediums such as neodymium:yttrium-aluminium-garnet (Nd:YAG),
carbon dioxide (CO2) or diodes. This laser light travels through a fiber-optic cable
which gets directed to the target tissue. This energy of light gets converted into
heat upon direct tissue contact thus causing tissue vaporization.
Nd:Yag and CO2 lasers can be useful for treating oral mucosal lesions. Since their
initial use in the excision of malignant and premalignant lesions in the oral cavity,
lasers have offered clinicians precise surgical management of oral soft tissue lesions,
with minimal postoperative pain and successful postoperative healing. CO2 laser
produces light at 10,600 nm wavelength. It is highly absorbed by water, and hydroxy-
apatite. The CO2 laser used in continuous wave, noncontact mode (coagulation) has
a large beam diameter that is advantageous for removing large leukoplakia lesions,

58 Chan & Wolf
Fig. 21. Illustration of excisional biopsy of soft tissue lesion. (A) Surface view. Elliptical inci-
sion is made around lesion, at least 3 mm away from lesion. (B) Side view. Incision is made
deep enough to remove lesion completely. (C) End view. Incisions are made convergent to
depth of wound. Excision made in this way facilitates closure. (From Hupp JR, Ellis III E,
Tucker MR. Contemporary oral and maxillofacial surgery. 5th edition. St Louis: CV Mosby;
2008. p. 436.)
Box 1
Instruments for biopsy
Gauze
Local anesthesia
Syringe
Scalpel with No. 15 blade
Tissue Pick-up (eg, Adson forceps with serrated teeth)
Suction
Needle holder
Scissors
Biopsy bottle with 10% formalin
Suture (3-0, 4-0 silk or chromic gut)
Michel’s solution and container for immunofluorescence study

such as those on the cheek and tongue. Nd:Yag produces light at 1,064 nm wave-
length and unlike the CO2 laser, it does not get well absorbed by water or hydroxy-
apatite. The Nd:YAG laser can operate in either noncontact (coagulation) or
contact mode (excision). It emits pulsed noncontinuous energy through a solid
core silica fiber the width of three human hairs. This mechanism makes the Nd:YAG
extremely precise and easy to use in areas around the dentition, where access is
more difficult for the CO2 laser or scalpel. The Nd:YAG is also less likely to cause
collateral damage to adjacent hard and soft tissue because of its smaller beam
size and short interaction times compared with continuous wave laser devices. Local
anesthesia is not needed if the setting is kept at 2W, 20 Hz. When selecting the power
setting for all laser devices, the minimum power required to produce the desired
effect should be chosen.22
New innovations in laser technology include the Odyssey Diode Laser by Ivoclar
Vivadent. It has both continuous and pulsed mode that produces light at 8101/20
nm wavelength. This wavelength is at the lower end of the infrared-spectrum making
it ideal for soft tissue biopsy and other soft tissue applications. There are 2 models
available Odyssey 2.4G and Odyssey Navigator. The Odyssey 2.4G is a table top
version and the Odyssey Navigator is more portable weighing in at 2.5 lbs. Another
Diode laser is the Picasso Laser by AMD Laser, LLC. There are 2 models available:
Picasso at 7 watts and Picasso Lite at 2.5 watts. Both laser units can provide GP
the power to treat most soft tissue procedures in office. The Picasso Lite 2.5 watts
laser, starts at $2495 making it an affordable entry unit.
COMMUNICATION WITH PATHOLOGIST
In performing a biopsy, the surgeon is communicating to the pathologist that the spec-
imen is a representation of the lesion itself. Surgeons can optimize that representation
in several ways.
Handling of Tissue
When performing the biopsy, the surgeon must avoid damaging the specimen. Local
anesthesia should be delivered as a field block or at least 1 cm away from the lesion to
avoid distorting the specimen. An Adson forceps with serrated teeth is the preferred
instrument to stabilize the lesion. Crushing the specimen is the commonest mistake
made by general practitioners.23
Orientation of Specimen
The orientation of the representative sample to the larger lesion or lesion margins is
often important to communicate to the pathologist. This information can be conveyed
by placing a suture through the edge of the lesion and marking it by a direction (ie,
anterior or superior). If the results indicate a malignancy, the general practitioner
can relay this information to the referring head and neck surgeon.
Describe Lesion to the Pathologist

Describing the lesion and providing important patient and clinical background
information (ie, size, shape, duration, growth pattern, color, mobility, lymph node
involvement) could help the pathologist diagnose the lesion. Description of the site
of each biopsy is especially important if more than one biopsy is being performed
from one lesion or numerous lesions.

60 Chan & Wolf
Transportation of the Specimen

To ensure the pathologist receives a correct representation, the specimen must not be
distorted during transportation from the general practitioner to the pathologist. Soon
after the specimen is removed, it should be placed in 10% formalin 10 the times the
volume of the specimen. If the general practitioner has vesiculobullous disease as
a differential diagnosis, the lesion should be placed in Michel’s solution for an immu-
nofluorescence study. CPT codes are D0482 and D0483 for direct and indirect immu-
nofluorescence studies, respectively.
DIAGNOSIS AND TREATMENT

Primary and Recurrent HSV
History and clinical presentation are usually enough to deduce a clinical diagnosis of
herpes virus infection. If uncertainty remains, laboratory tests are available to help
confirm the diagnosis. Before using any of the tests discussed, the general practitioner
should contact a local laboratory to determine the availability and turnaround time for
each test (Fig. 22).
Viral culture is a collection of the virus at its most virulent stage. An excisional biopsy
of the intact vesicle is the most ideal procedure to capture the virus. Alternatively,
a needle aspiration from an intact vesicle would yield the best viral content. If a needle
aspiration is not available or the general practitioner is uncomfortable with this tech-
nique, then the viral fluid can be collected through bursting a fresh vesicle and using
a cotton swab for sampling. A skin sample must also be collected for viral culture
because the virus hides in the skin cells; this is why the virus is very contagious in
shedding stages during an active outbreak. Results of the culture will take 2 to 4
days depending on the laboratory’s methods. The CPT code for reimbursement for
viral culture is D0416.
A herpes virus antigen detection test requires fresh sores to be obtained. It detects
marker antigens on the infected host’s cell. A positive test indicates herpes virus. This
test can be substituted for the viral culture.
R/O Herpes Simplex Virus (HSV)
Direct Indirect
Intact Vesicle?
PCR (DNA)
Serology
Blood, Spinal
(blood)-
Fluid, Tears,
No antibody levels
yes Urine
(Ruptured)
PCR Biopsy for Cytological Viral antigen

-swab Viral Culture Smear test
Needle Aspirate or
Excisional Biopsy
Direct Swab
Fig. 22. HSV flow chart.

Unlike with viral culture, samples for cytology are collected from a ruptured vesicle.
A cytology smear requires viral fluid from the vesicle to be placed on the glass slide so
that it can viewed under a microscope. The CPT code for reimbursement for exfoliative
cytology is D7287. This test, however, is not specific for HSV-1 because HSV-2 can
have similar histologic features.
Although not as readily available as viral culture, polymerase chain reaction (PCR)
test helps to detect the herpes virus’s DNA. PCR is performed using the same collec-
tion method as the viral culture. Samples can also be collected from blood, spinal fluid,
urine, or tears.
For an indirect test method, serology requires blood collection to detect HSV anti-
body level in the serum against specific viral antigens. The presence of the antibodies
cannot be distinguished between an active or previous infection; this only reveals the
host’s immune response to the herpes virus. A false-positive can also occur for recent
infection when the body has not mounted an immune response.
A common microscopic feature seen in a herpes virus infection is ballooning degen-
eration of the keratinocytes, multinucleated epithelial cells, and inclusion bodies
(Fig. 23).
Treatment of primary herpetic gingivostomatitis is nonspecific and consists of palli-
ative care during the acute phase (eg, increased fluid intake, antipyretics, topical or
elixir analgesia). Topical benzocaine 20% (oral gel) applied to affected regions can
Fig. 23. Herpes simplex. Early and late stages of intraepithelial viral vesicle formation. (A)
Incipient vesicle formation early in prodromal stage before presence of a clinically visible
vesicle exhibiting ballooning degeneration, nuclear margination, and multinucleation of
the spinous layer of keratinocytes (viral cytopathic changes) (Hematoxylin and eosin
[H&E], high power magnification). (B) Fully developed but intact intraepithelial viral vesicle
that contains fluid, virally altered keratinocytes, large numbers of viruses, and necrotic
debris (H&E, medium power magnification). (C) Photomicrograph of cytologic smear of viral
vesicle contents that reveals enlarged and ballooned keratinocytes and associated leuko-
cytes. (From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial

62 Chan & Wolf
provide temporary relief. If lesions are diffuse, then 1 to 2 teaspoons of Hurricane

elixir in 500 mL can be swished and expectorated every 2 hours as needed for
pain. Hurricane elixir has three active ingredients in equal quantity in the mixture:
Mylanta, 2% Xylocaine, and 12.5 mg/5 mL diphenhydramine. Mylanta helps to
coat the lining of the mouth thus giving the elixir a longer-lasting effect (Box 2).
Acyclovir is not indicated for healthy patients and has little clinical effects on estab-
lished lesions.
Although recurrent intraoral herpes (stomatitis) responds poorly to local antiviral
agents, palliative remedies are usually prescribed for this condition until the virus
runs its course. Over-the-counter (OTC), topical analgesia Lipactin gel and Zilactin
can help control pain. However, treatment for recurrent herpes labialis using antiviral
agents is effective only during the prodrome phase (Box 3). This treatment helps
reduce healing time, viral shedding, and pain. The only available OTC medication
is docosanol (Abreva) 10% cream, which helps to reduce healing time. Acyclovir
(Zovirax) and penciclovir (Denavir) creams are antiviral agents approved by the U.S.
Food and Drug Administration (FDA) for the treatment of herpes labialis. To be effec-
tive, acyclovir cream 0.5% must be applied five times per day for 4 days, and penci-
clovir (Denavir) topical cream 1% applied every 2 hours for 4 days. In 2009, the FDA
approved a combination of 5% acyclovir and 1% hydrocortisone cream (Xerese) for
the treatment of recurrent herpes labialis. The added corticosteroids help decrease
local inflammation, which helps shorten the clinical course and vesicular outbreaks
compared with acyclovir alone.24 For patients who experience recurrent outbreaks
(ie, two in 4 months), three antiviral oral medications are approved by the FDA to
help shorten the clinical course. Acyclovir (Zovirax), 400 mg, taken orally five times
per day for 4 days, valacyclovir (Valtrex), 2.0 g, taken orally every 12 hours for
1 day, and famciclovir (Famvir), 1500 mg, taken orally for 1 day. Acyclovir is used
for immunocompetent patients, whereas famciclovir is reserved for those who are
immunocompromised.
Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis is diagnosed based on clinical appearance alone. If
any associated systemic disease is present, the patient should be referred to a physi-
cian. The mainstay of treatment of RAS is still corticosteroids, although topical anal-
gesia can be used to alleviate pain. The topical form is used to treat mild to moderate
conditions, whereas systemic is reserved for severe conditions (Box 4). Clobetasol
propionate 0.05% and triamcinolone in Orabase 0.1%, with 15 g each equally mixed,
Box 2
Topical and elixir analgesia for primary herpetic gingivostomatitis
Local sites
Benzocaine (oral gel) 20%
Disp: 1 tube
Sig: apply to lesion every day as needed
Diffuse lesions
Hurricane elixir
Disp: 500 mL
Sig: 1–2 teaspoons every 2 hours as needed, swish and expectorate

Box 3
Antiviral medicationsa
Over-the-counter
Docosanol (Abreva)
Disp: 2 g tube
Sig: apply to lesion five times per day for 4 days
Topical prescription
Acyclovir 0.5% (Zovirax) cream
Disp: 5 g tube
Sig: apply five times per day
Penciclovir 1% (Denavir) cream
Disp: 1.5 g
Sig: apply to lesion every 2 hours for 4 days
Acyclovir 5% and Hydrocortisone 1% (Xerese)
Disp: 1 tube
Sig: apply five times per day
Oral prescription
Acyclovir (Zovirax), 400 mg
Disp: 20 tablet
Sig: 1 tablet by mouth five times per day
Valacyclovir (Valtrex), 2000 mg
Disp: 2 tablets
Sig: 1 tablet by mouth every 12 hours for 1 day
Famciclovir (Famvir), 1500 mg
Disp: 1 tablet
Sig: 1 tablet by mouth for 1 day
a
Applied or used when symptoms first occur.
should be applied (but not rubbed) to affected areas three times daily.4 For diffused
lesions, one teaspoon of dexamethasone elixir, swished and expectorated 4 to 5
times per day, can be very effective. One study suggested that this local corticoste-
roid therapy does not produce any adrenal suppression despite long-term or
repeated use.6 Intralesional triamcinolone 0.1% in 1 mL can be used to treat large
aphthae lesions.
Alternatives to topical corticosteroids are available for treating RAS. Amlexanox
(Aphthasol) is an FDA-approved noncorticosteroid medication that has antiallergic
and antiinflammatory properties. It comes in a 5% paste and should be applied two
to four times daily. It helps reduce size and pain level, which speeds up recovery.25–29
The only adverse effects of this drug is a stinging sensation at the site of application.30
Hurricane elixir is good for diffused intraoral lesions. Chlorhexidine helps reduce the
duration of RAS through its antimicrobial effects.31–34
Other agents on the market are notable for treating RAS. Tacrolimus ointment 0.1%
is an immunosuppressant medication that should only be used in healthy patients. It

64 Chan & Wolf
Box 4
Treatment for recurrent aphthous stomatitis
Clobetasol propionate 0.05% and triamcinolone in Orabase 0.1%

Disp: 15 g each
Sig: mix and apply to lesion (do not rub) three times daily
Hurricane elixir
Disp: 500 mL
Sig: 1 to 2 teaspoons every 2 hours as needed, swish and expectorate
Dexamethasone 0.5 mg/mL elixir
Disp: 500 mL
Sig: 1 teaspoon every 6 hours, swish and expectorate
Noncorticosteroid alternative
Amlexanox 5% oral paste (Aphthasol)
Disp: 5 g tube
Sig: apply to lesion every 6 hours as needed for pain
Chlorhexidine oral rinse
Disp: 1 bottle (2-week supply)
Sig: 20 mL for 30 seconds three times daily, swish and expectorate
inhibits T-lymphocyte activation, which can be detrimental in immunocompromised

patients. Triclosan mouthrinse has antiinflammatory, analgesic, and antimicrobial
properties, which help reduce the duration of ulcers in the oral cavity.35 Tetracycline
(eg, aureomycin, chlortetracycline, and tetracycline) helps reduce the healing time
and pain. The British National Formulary included 100 mg of doxycycline mixed in
10 mL of water for 2 to 3 minutes every day for 3 days for the treatment of
RAS.36–39 Referral to a physician is prudent if systemic agents are needed. Predni-
sone or azathioprine should be reserved for patients with severe RAS otherwise
refractory to local treatments. Thalidomide has been an effective alternative agent
to steroids. It is a water-soluble macrolide that has antiinflammatory and anti-
immunologic properties for suppressing T-cell function. Thalidomide used in 50- to
100 mg dosages every day has significant clinical effects against RAS. However,
serious adverse reaction haven been reported with this drug, including teratogenicity,
neuropathy, somnolence, constipation, rash, thromboembolic, and neutropenia.40
Furthermore, one tablet at taken at day 20 of pregnancy can cause phocomelia.41
Lastly, dapsone is an immunomodulatory agent that has shown to be effective in
the treatment of RAS.42
Lichen Planus
Diagnosis of LP is based on clinical examination, histology, and direct immunofluores-
cence studies. Reticular LP can often be diagnosed through clinical findings alone. For
erosive LP, a biopsy is often necessary to rule out other ulcerative diseases or prema-
lignant changes. Histologic features of LP include epithelial acanthosis, hyperkera-
tosis, basal cell layer vacuolation, sawtooth rete, and dense band-like infiltrate of

T lymphocytes below the basement membrane (subbasilar) (Fig. 24). Direct immuno-
fluorescence study will show a linear deposit of fibrinogen at the basement membrane
(Fig. 25).
Reticular LP typically produces no symptoms and no treatment is required.
Erosive LP, however, is often painful because of open sores. Because it is an
immune-based disease, corticosteroids are recommended. The objective is to
use the shortest course (1–2 weeks) of steroids without causing potential side
effects (eg, immunosuppression, fungal over growth). Topical corticosteroids,
such as clobetasol propionate 0.05% with triamcinolone in Orabase 0.1%, and
dexamethasone elixir can be used as first-line therapy (Box 5). Intralesional injection
of triamcinolone 0.1% in 1 mL has been used for resistant local steroid therapy. One
study suggests Portulaca oleracea L or Purslane, 235 mg, orally every day is
effective in treating oral lichen planus, with an 83% success rate after 2 weeks.43
Purslane is a herbaceous weed found in the Tehran province in Iran that has anti-
inflammatory, antiulcerogenic, antifungal, and antioxidant properties. Topical or
systemic thalidomide has shown to be effective as an alternative for steroid therapy
after 1 week of application,40 with 54.5% and 66.7% of patients treated success-
fully after 1 week and 1 month, respectively. Again, physicians should use this
medication cautiously with the understanding that significant adverse reactions
were reported in other studies.
Mucous Membrane Pemphigoid

A dominant histopathologic picture of MMP shows a separation of the epithelium from
the connective tissue layer (Fig. 26). These autoantibodies (IgG, IgA, or both) are
Fig. 24. LP. Microscopic features showing the characteristic narrow dense band of T lympho-
cytes in the immediately adjacent connective tissue of reticular LP (A) and atrophic and
erosive LP (B). (C) High power magnification of A. (A, C, H&E; A, low power; B, medium
power and it’s a diagram; C, high power.) (From Sapp JP, Eversole LR, Wysocki GP. Contem-
porary oral and maxillofacial pathology. 2nd edition. Mosby; 2004. p. 260; with permission.)

66 Chan & Wolf
Fig. 25. LP. Photomicrograph of immunofluorescent pattern of linear deposit of fibrinogen

at the basement membrane (low power magnification). (From Sapp JP, Eversole LR, Wysocki
GP. Contemporary oral and maxillofacial pathology. 2nd edition. Mosby; 2004. p. 261; with
permission.)
believed to attack the antigen sites between this layer, causing a separation. The
antigen sites are BP18044,45 and Laminin-5.46,47 Direct immunofluorescence shows
a linear deposition of complement (IgG, IgA, C3, or a combination) at the basement
membrane zone. Indirect immunofluorescence has no value because circulating anti-
bodies are not detectable at the basement membrane (Fig. 27).
Treatment of oral MMP depends on the severity and location of the lesion. If the
lesion is mild to moderate and is confined to the gingiva and palate, then a custom
tray with clobetasol propionate 0.05% and triamcinolone in Orabase 0.1% can be
used.9 Dexamethasone elixir is a good first choice for diffused intraoral lesions
Box 5
Treatment for oral erosive lichen planus

Disp: 15 g each
Disp: 500 mL (1-week supply with refills as needed)
Purslane, 235 mg
Disp: 14 tablets
Sig: 1 tablet by mouth every day

Fig. 26. MMP. Photomicrograph of mucosa showing lack of rete pegs and loss of adhesion
of the epithelium with cleavage at the level of the basement membrane. (A) H&E, medium
power magnification; (B) it is a diagram of A. (From Sapp JP, Eversole LR, Wysocki GP.
permission.)
(Box 6). Large local lesions can be treated with intralesional injection of triamcinolone
0.1%. Systemic corticosteroids are reserved for patients who experience no response
to local therapy. Burst therapy is described as a short course of 60–80 mg of systemic
prednisone for several days, followed by 7 to 10 days of maintenance and tapered
dosage. Alternative or “steroid sparing” medications are available. Dapsone (Avlosul-
fon) is an antimicrobial agent with immunosuppressive activity that has been shown to
be somewhat effective.48–50 Tacrolimus, retinoids, and cyclosporine have been used
effectively against vesiculobullous disease.51–53 Immunosuppressive agents, such as
Fig. 27. MMP. Immunofluorescence reveals a solid yellow-green line, indicating the pres-
ence of IgG antibody complexed to the antigen at the basement membrane. (From Sapp
JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd edition.

68 Chan & Wolf
Box 6
Treatment for oral mucous membrane pemphigoid

Disp: 15 g each
Disp: 500 mL
azathioprine, methotrexate, and cyclophosphamide, in combination with systemic

steroids is also effective in treating severe cases.
Pemphigus Vulgaris
PV is diagnosed based on clinical, histologic, and direct and indirect immunofluores-
cence studies. Histologically, PV has a typical blister formation showing edematous
keratinocytes (Tzanck cells) detached from surrounding cells (acantholysis). An inflam-
matory infiltrate is dominated by mononuclear cells in the connective tissue (Fig. 28).
Unlike MMP, which has a subepithelial separation, PV has intraepithelial separation
caused by antibody (IgG) binding to antigen desmoglein 3. Direct immunofluores-
cence is used as an adjunct to confirm the diagnosis. This study shows binding of
IgG and C3 in the intercellular epithelium resulting in a reticular pattern, which is clas-
sically known as the “chicken wire” appearance (Fig. 29). No staining occurs in the
basement membrane zone; however, indirect immunofluorescence study shows
a positive detection of autoantibodies at the basement.
Topical and elixir corticosteroids are used to treat oral PV (Box 7).54 Intralesional
triamcinolone may be used as second-line treatment. Systemic corticosteroids are
reserved for severe cases (Box 8). In the first week, 60 to 80 mg of prednisone to
be taken orally every day is prescribed. Follow-up after the first week will dictate
how the remainder of the regimen is prescribed. If the blisters continue to appear,
Fig. 28. PV. Photomicrograph of epithelium exhibiting rete pegs and a zone of acantholysis
above the basal cell layer. Spinous cells (Tzanck cells) are present and floating freely in the
fluid-filled intraepithelial space. (A) High power magnification, (B) it is a diagram of A.
(From Sapp JP, Eversole LR, Wysocki GP. Contemporary oral & maxillofacial pathology. 2nd

Fig. 29. PV. Immunofluorescent pattern of the IgG antibody adherence to the desmosomal
protein (desmoglein) located on the periphery of epithelial intermediate cells, producing
a “fishnet” pattern of binding sites (high power magnification). (From Sapp JP, Eversole
LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd edition. Mosby;
Box 7
Treatment for oral pemphigus vulgaris
Clobestasol propionate 0.05% and triamcinolone in Orabase 0.1%

Disp: 15 g each
Disp: 500 mL
Box 8
Systemic steroids (Consult M.D.)
60 -80 mg PO QD x
Week 1
1 week
If no resolution 120 mg to 240 mg

after 1 week PO x QD x 1 week
Reduce dosage by
40 mg Reduce dose by
half when lesion is
half Q4 monthly
controlled until 40

70 Chan & Wolf
then the physician can increase the dose to 120 mg or up to 240 mg to be taken orally
every day for the following week. If clinical evidence shows tight control of disease
progression, the current dosage can be reduced by half weekly until 40 mg/d is
reached. At that time, the 40 mg dosage is then decreased every 4 months.55 For
most patients, low maintenance doses, usually every other day, are needed for years.
High-dose pulses of corticosteroids may be delivered for relapsing or resistant cases,
either orally or intravenously. Adverse side effects of corticosteroids can overwhelm
the patient’s adrenal system, causing cushingoid symptoms. As an alternative to
systemic corticosteroids, immunosuppressant and antimicrobial agents, similar to
those used for MMP, can be applied to PV successfully.
Erythema Mulitforme
EM is diagnosed based on the exclusion of other vesiculobullous diseases. The histo-
pathology is not pathognomonic. Intercellular and intracellular edema overlying the
epithelium is seen, with focal microvesicle formation (Fig. 30). Direct and indirect
immunofluorescence studies have no diagnostic value. Treatment is directed toward
treating or removing the offending agent (eg, HSV, drug-induced). Mild symptoms can
be controlled by administering analgesic and antipyretics or topical steroids. Patients
with severe symptoms should be admitted in the hospital to control body fluid, elec-
trolyte losses, and infection. Systemic steroid or immunosuppressant therapy may be
needed to control lesion progression.
Lupus Erythematosus
Lupus erythematosus is diagnosed using the following tests. Direct immunofluores-
cence will be positive for IgA, IgM, and IgG immunoglobulins, fibrinogen, and C3. Indi-
rect immunofluorescence will be negative. SLE is diagnosed based on analysis of
antinuclear antibodies to doubled-stranded DNA, detection of and serum rheumatoid
factors, and a lupus erythematosus cell test.
Treatment of DLE is with topical steroid antimalarials and sulfones. The more severe
form requires steroids or combination of steroids and immunosuppressive drugs, such
as cyclophosphamide and azathioprine. Systemic steroid are reserved for oral forms
that are refractory to local treatment.
Fig. 30. EM. Photomicrograph of mucosal tissue with extensive intraepithelial pooling of
eosinophilic coagulum, separation of the epithelium from connective tissue (bulla forma-
tion), and intense chronic inflammatory cell infiltrates. (A) High power magnification
with H&E stain, (B) it is a diagram of A. (From Shklar G. Oral lesions of erythema multiforme:
histologic and histochemical observations. Arch Dermatol 1965;92:495; and Sapp JP, Eversole
LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd edition. Mosby; 2004.
p. 273; with permission.)

SUMMARY
Oral mucocutaneous diseases are common encounters in the daily dental practices, the
general practitioner should have a heightened ability to recognize abnormal tissues. A
through and systemic approach to these lesions requires a working diagnosis through
history, clinical examination, and biopsying of lesions. Proper referral to medical
specialists can prevent certain comorbidities and mortalities.
ACKNOWLEDGMENTS
The authors want to extend a very special thanks to Fran Tidona (Chief, Library
Service at Brooklyn Campus) for her tireless pursuit to help gather numerous articles
for us.
REFERENCES
1. Shulman J, Beach M, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in

U.S. adults: data from the Third National Health and Nutrition Examination Survey,
1988-1994. J Am Dent Assoc 2004;135:1279.
2. Shulman J, Beach M, Rivera-Hidalgo F. Prevalence of oral mucosal lesions in
children and youths in the USA. Int J Paediatr Dent 2005;15:89.
3. American Dental Association. The 2005-06 Survey of Dental Services Rendered.
ADA; 2007.
4. Kerpel S, Freedman P, Reich R. A comprehensive review course in oral pathology
[handout]. 2002.
5. Sapp JP, Eversole LR, Wysocki GP. Contempoary oral & maxillofacial pathology.
2nd edition. St. Louis (MO): Mosby; 2004. p. 210–3.
6. Scully C, Porter S. Oral mucosal disease: recurrent aphthous stomatitis. Br J Oral
Maxillofac Surg 2008;46:198–206.
7. Scully C, Porter S. Recurrent aphthous stomatitis: current concepts of etiology,
pathogenesis and management. J Oral Pathol Med 1989;18:21–7.
8. Thorn JJ, Holstrupp P, Rindum H, et al. Course of various clinical forms of oral
lichen planus. A prospective follow-up study of all 611patients. J Oral Pathol
Med 1988;17:213–318.
9. Toscano NJ, Holtzclaw DJ, Shumaker ND. Surgical considerations and manage-
ment of patients with mucocutaneous disorders. Compend Contin Educ Dent
2010;31:346.
10. Rogers RS III, Eisen D. Erosive OLP with genital lesions. The vulvovaginal-
gingival syndrome and peno-gingival syndrome. Dermatol Clin 2003;21(1):
79–89.
11. Anderson JO. OLP: a clinical evaluation of 115 cases. Oral Surg Med Oral Pathol
1968;23(1):31–41.
12. Lourenco SV, Boggio P, Agner Macado Martins LE, et al. childhood oral mucous
membrane pemphigoid presenting as desquamative gingivitis in a 4-year-old girl.
Acta Derm Venereol 2006;86(4):351–4.
13. Endo H, Rees TD, Kuyama K, et al. Clinical and diagnostic features of mucous
membrane pemphigoid. Compend Contin Educ Dent 2006;27(9):512–8.
14. Suresh L, Kumar V. Significance of IgG4 in the diagnosis of mucous membrane
pemphiogoid. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104(3):
359–62.
15. Scully C, Challacombe SJ. Pemphigus: update on etiopathogenesis, oral mani-
festations, and management. Crit Rev Oral Boil Med 2002;13(5):397–408.

72 Chan & Wolf
16. Zunt S. Transepithelial brush biopsy: an adjunctive diagnostic procedure.

J Indiana Dent Assoc 2001;80(2):6–8.
17. Sciubba J. Improving detection of precancerous and cancerous oral lesions.
Computer-assisted analysis of the oral brush biopsy. U.S. Collaborative OralCDx
Study Grooup. J Am Dent Assoc 1999;(30):1445–57.
18. Hohlweg-Majert B, Deppe H, Metzger MC. Sensitivity and specificity of oral brush
biopsy. Cancer Invest 2009;27:293–7.
19. Golden D, Hooley J. Oral mucosal biopsy procedures. Excisional and incisional.
Dent Clin North Am 1994;38(2):279–300.
20. Marx RE, Stern D. Oral and maxillofacial pathology: a rationale for diagnosis and
treatment. Carol Stream (IL): Quintessence books; 2003. p. 1–15.
21. Lynch D, Morris L. The oral mucosal punch biopsy: indications and technique.
J Am Dent Assoc 1990;121:145–9.
22. White J, Chaudhry S. Nd:Yag and CO2 Laser Therapy of Oral mucosal Lesions.
J Clin Laser Med Surg 1998;16(6):299–304.
23. Oliver R, Sloan P. Oral Biopsies: methods and applications. Br Dent J 2004;
196(6):329–33.
24. Hull C, Brunton S. The role of topical 5% acyclovir and 1% hydrocortisone cream
(xerses) in the treatment of recurrent herpes simplex labialis. Postgrad Med 2010;
122(5):1–6.
25. Kwandala A. 5% amlexanox oral paste, a new treatment for recurrent minor aph-
thous ulcers: I. Clinical demonstration of acceleration of healing and resolution of
pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83(2):222–30.
26. Greer RO Jr, Lindenmuth JE. A double-blind study of topically applied 5% amlex-
anox in the treatment of aphthous ulcers. J Oral Maxillofac Surg 1993;51(3):243–8
[discussion: 248–9].
27. Binnie WH, Curro FA. Amlexanox oral paste: a novel treatment that accelerates
the healing of aphthous ulcers. Compend Contin Educ Dent 1997;18(11):
1116–8, 1120–2, 1124 passim.
28. Murray B, McGuinness N, Biagioni P, et al. A comparative study of the efficacy of
Aphtheal in the management of recurrent minor aphthous ulceration. J Oral Pathol
Med 2005;34(7):413–9.
29. Murray B, Biagioni PA, Lamey PJ. The efficacy of amlexanox OraDisc on the
prevention of recurrent minor aphthous ulceration. J Oral Pathol Med 2006;
35(2):117–22.
30. Khandwala A, Van Inwegen RG, Charney MR, et al. 5% amlexanox oral paste,
a new treatment for recurrent minor aphthous ulcers: II. Pharmacokinetics and
demonstration of clinical safety. Oral Surg Oral Med Oral Pathol Oral Radiol En-
dod 1997;83(2):231–8.
31. Addy M, Tapper-Jones L, Seal M. Trial of astringent and antibacterial mouth-
washes in the management of recurrent aphthous ulceration. Br Dent J 1974;
136(11):452–5.
32. Addy M, Carpenter R, Roberts WR. Management of recurrent aphthous ulcera-
tion. A trial of chlorhexidine gluconate gel. Br Dent J 1976;141(4):118–20.
33. Addy M. Hibitane in the treatment of aphthous ulceration. J Clin Periodontol 1977;
4(5):108–16.
34. Hunter L, Addy M. Chlorhexidine gluconate mouthwash in the management of
minor aphthous ulceration.A double-blind, placebo-controlled cross-over trial.
Br Dent J 1987;162(3):106–10.
35. Greenspan JS, Gadol N, Olson JA, et al. Antibody-dependent cellular cytotoxicity
in recurrent aphthous ulceration. Clin Exp Immunol 1981;44(3):603–10.

36. Guggenheimer J, Brightman VJ, Ship II. Effect of chlortetracycline mouthrinses

on the healing of recurrent aphthous ulcers: a double-blind controlled trial.
J Oral Ther Pharmacol 1968;4(5):406–8.
37. Graykowski EA, Kingman A. Double-blind trial of tetracycline in recurrent
aphthous ulceration. J Oral Pathol 1978;7(6):376–82.
38. Denman AM, Schiff AA. Recurrent oral ulceration treated with Mysteclin:
a controlled study. Br Med J 1979;1(6173):1248–9.
39. Häyrinen-Immonen R, Sorsa T, Pettilä J, et al. Effect of tetracyclines on collage-
nase activity in patients with recurrent aphthous ulcers. J Oral Pathol Med
1994;23(6):269–72.
40. Wu Y, Zhou G, Zeng H. A Randomized double-blind, positive-control trail of
topical thalidomide in erosive oral lichen planus. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2010;10:188–95.
41. Porter SR, Jorge J Jr. Thalidomide: a role in oral oncology? Oral Oncol 2002;38:
527–31.
42. Handfield-Jones S, Allen BR, Littlewood SM. Dapsone use with oral-genital
ulcers. Br J Dermatol 1985;113:501.
43. Agha-Hosseini F, Borhan-Mojabi K, Monsef-Esfahani HR. Efficacy of purslane in
the treatment of oral lichen planus. Phytother Res 2010;24:240–4.
44. Kromminga A, Sitaru C, Meyer J, et al. Cicatricial pemphigoid differs from bullous
pemphigoid and pemphigoid gestationis regarding the fine specificity of autoan-
tibodies to the BP180 NC16A domain. J Dermatol Sci 2002;28(1):68–75.
45. Roh JY, Yee C, Lazarova Z, et al. The 120-kDa soluble ectodomain of type XVII
collagen is recognized by autoantibodies in patients with pemphigoid and linear
IgA dermatosis. Br J Dermatol 2000;143(1):104–11.
46. Sakamoto K, Mori K, Hashimoto T, et al. Antiepiligrin cicatricial pemphigoid of the
larynx successfully treated with a combination of tetracycline and niacinamide.
Arch Otolaryngol Head Neck Surg 2002;128(12):1420–3.
47. Parisi E, Raghavendra S, Werth VP, et al. Modification to the approach of the
diagnosis of mucous membrane pemphigoid: A case report and literature review.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95(2):182–6.
48. Ciarrocca KN, Greenberg MS. A retrospective study of the management of oral
mucous membrane pemphigoid with dapsone. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 1999;88(2):159–63.
49. Ahmed AR, Colón JE. Comparison between intravenous immunoglobulin and
conventional immunosuppressive therapy regimens in patients with severe oral
pemphigoid: effects on disease progression in patients nonresponsive to
dapsone therapy. Arch Dermatol 2001;137(9):1181–9.
50. Kirtschig G, Murrell D, Wojnarowska F, et al. Interventions for mucous membrane
pemphigoid/cicatricial pemphigoid and epidermolysis bullosa acquisita:
a systematic literature review. Arch Dermatol 2002;138(3):380–4.
51. Chainani-Wu N, Silverman S Jr, Lozada-Nur F, et al. Oral lichen planus: patient
profile, disease progression and treatment responses. J Am Dent Assoc 2001;
132(7):901–9.
52. Stanley JR. Therapy of pemphigus vulgaris. Arch Dermatol 1999;135(1):76–8.
53. Fine JD. Management of acquired bullous skin diseases. N Engl J Med 1995;
333(22):1475–84.
54. Darling M, Daley T. Blistering mucocutaneous disease of the oral mucosa—a review:
part 1. Mucous membrane pemphigoid. J Can Dent Assoc 2005;71:851–4.
55. Darling MR, Daley T. Blistering mucocutaneous diseases of the oral mucosa—
a review: part 2. Pemphigus vulgaris. J Can Dent Assoc 2006;72(1):63–6.


Biopsy Techniques

Uploaded by

Copyright:

Available Formats

Biopsy Techniques

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Biopsy Techniques

Uploaded by

Copyright:

Available Formats

B i o p s y Te c h n i q u e s

and Diagnoses &

The authors have nothing to disclose.

Dent Clin N Am 56 (2012) 43–73

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Recurrent Aphthous Stomatitis

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Mucous Membrane Pemphigoid

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Long standing Bulla (with epithelium)

Take lesion with

Fig. 18. Biopsy technique for oral mucocutaneous lesion.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Laser is an acronym for “Light Amplification by Stimulated Emission of Radiation.”

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

COMMUNICATION WITH PATHOLOGIST

Describe Lesion to the Pathologist

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Transportation of the Specimen

DIAGNOSIS AND TREATMENT

R/O Herpes Simplex Virus (HSV)

PCR Biopsy for Cytological Viral antigen

Fig. 22. HSV flow chart.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

provide temporary relief. If lesions are diffuse, then 1 to 2 teaspoons of Hurricane

Recurrent Aphthous Stomatitis

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Clobetasol propionate 0.05% and triamcinolone in Orabase 0.1%

inhibits T-lymphocyte activation, which can be detrimental in immunocompromised

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Mucous Membrane Pemphigoid

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Fig. 25. LP. Photomicrograph of immunofluorescent pattern of linear deposit of fibrinogen

Clobetasol propionate 0.05% and triamcinolone in Orabase 0.1%

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Clobetasol propionate 0.05% and triamcinolone in Orabase 0.1%

azathioprine, methotrexate, and cyclophosphamide, in combination with systemic

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Clobestasol propionate 0.05% and triamcinolone in Orabase 0.1%

If no resolution 120 mg to 240 mg

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

1. Shulman J, Beach M, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.

16. Zunt S. Transepithelial brush biopsy: an adjunctive diagnostic procedure.

Downloaded from ClinicalKey.com at University of Qatar February 12, 2017.