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Home , Epulis fissuratum, Granular cell tumor, Sarcoma, Spindle cell lipoma

2018 Self-Study Course #4 Course

Course Instructions:

. Read and review the course materials. . Complete the 16 question test. A total of 12 questions must be answered correctly for credit. . Submit your answers online at: http://dentistry.osu.edu/sms- Frequently Asked Contact Us: continuing-education Questions: . Check your email for your CE Q: Who can earn FREE CE credits? Phone certification of completion (please check your junk/spam 614-292-6737 A: EVERYONE - All dental professionals folder as well). in your office may earn free CE credits. Each person must read the course Toll Free materials and submit an online answer 1-888-476-7678 About SMS CE courses: form independently. . TWO CREDIT HOURS are issued Q: Where can I find my SMS number? Fax for successful completion of this self-study course for the OSDB A: Your SMS number can be found in the 614-292-8752 2017-2018 biennium totals. upper right hand corner of your monthly reports, or, imprinted on the back of . CERTIFICATE of COMPLETION E-mail is used to document your CE your test envelopes. The SMS number is the account number for your office only, [email protected] credit and is emailed to each course participant. and is the same for everyone in the office. . ALLOW 2 WEEKS for processing Web of your certificate. Q: How often are these courses dentistry.osu.edu/sms available? A: Four times per year (8 CE credits).

The Ohio State University College of Dentistry is a recognized provider for ADA CERP credit. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints The Ohio State University about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at www.ada.org/cerp. College of Dentistry The Ohio State University College of Dentistry is approved by the Ohio State Dental Board as a 305 W. 12th Avenue permanent sponsor of continuing dental education. Columbus, OH 43210 This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between The Ohio State University College of Dentistry Office of Continuing Dental Education and the Sterilization Monitoring Service (SMS). 2018 & Course Techniques #4 This is an OSDB Category B: Supervised self-instruction course

About the Author Caroline Bissonnette, DMD Dr. Caroline Bissonnette obtained her D.M.D. from the University of Montreal in 2016. She then completed a general practice residency at the University of Montreal and Notre Dame Hospital in 2017. During this time, she gained experience in oral , oral medicine and oral . She is currently the 2nd year resident in the Oral and Maxillofacial Pathology program at the Ohio Written by: State University. Dr. Bissonnette has Caroline Bissonnette, DMD published two peer-reviewed articles in the fields of oral pathology and oral medicine.

Edited by: Dr. Bissonnette can be reached at Sydney Fisher, MPH [email protected] Nick Kotlar, BS Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my judgement with regard to the content of this course.

Release Date: October 22, 2018 8:30am EST Educational Objectives Last Day to Take Course 1. Review the common benign oral soft tissue lesions. Free of Charge: November 22, 2018 2. Identify clinical features to help elaborate a 4:30pm EST differential diagnosis. 3. Determine management and prognosis for oral soft tissue lesions. 4. Review common biopsy techniques and identify potential pitfalls.

2 Disclaimer This review is not exhaustive and contains the most common oral soft tissue lesions encountered in a dental practice. Although clinical follow-up may be an acceptable plan, histopathological analysis is required to achieve a definitive diagnosis, which cannot be obtained based on clinical features alone.

Hopefully, this course will enable the clinician to elaborate a differential diagnosis and determine the appropriate treatment plan. Furthermore, common surgical techniques will be discussed to enhance the dentist's skillset. When in doubt, referral to a specialist (oral pathologist or oral surgeon) remains the recommended course of action. Part I Oral Soft Tissue Lesions Clinical Features: • Firm, pink, smooth • Either sessile or pedunculated • May show superficial ulceration or hyperkeratinization if frequently traumatized • Stable in size or slowly growing Common Sites: • Buccal mucosa, particularly along the plane of occlusion • • • Gingiva Treatment: Complete excision Prognosis: Excellent, but may recur if site is repeatedly traumatized

© Caroline Bissonnette

© Caroline Bissonnette

40 x Giant Fibroma Clinical Features: • Firm, pink, nodule that may have a papillary surface (Can be mistaken for a papilloma • Either sessile or pedunculated • Typically less than 1 cm in size

Common Sites: • Gingiva = 50 % cases • Tongue,

Treatment: Complete excision

Prognosis: Excellent. Recurrence is rare

Arrows highlight the stellate shaped and multinucleated fibroblasts seen in giant cell Retrocuspid Papilla Microscopically similar to the giant cell fibroma, the retrocuspid papilla is a pink that occurs on the lingual gingiva of the mandibular cuspid.

It is typically bilateral and is more frequent in young adults. The prevalence decreases with age. Due to its characteristic appearance and Photo credit: Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2016). Oral and site distribution, maxillofacial pathology (Fourth edition.). St. excision is not required. Louis, Missouri: Elsevier. Inflammatory Fibrous Consists of hyperplastic . Also known as fissuratum. Clinical Features: • Firm, hyperplastic tissue folds • May be erythematous and ulcerated • Typically associated with an ill-fitting denture Common Sites: • Alveolar vestibule (mostly on the facial aspect, but may be seen on the lingual) • Anterior or maxilla more commonly. Can occur posteriorly Age/Sex Predilection: Adults. F > M Treatment: Surgical excision and adjustment or confection of new Prognosis: Excellent.

Other Types of Fibrous Hyperplasia

Leaf-like fibroma: Occurs on the palate beneath an ill-fitting denture. Appears as a pink, flat, pedunculated mass. Usually asymptomatic.

Fibrous hyperplasia: • Also referred to as peripheral fibroma in the literature • Reactive hyperplasia can occur on the gingiva as a result of chronic irritation • It will present as a pink mass that may sessile or pedunculated and is associated with a local source of irritation such as calculus/plaque or defective restorations • More common on the anterior maxillary gingiva • Authors suggest that this may present a that has undergone fibrous maturation Pyogenic Granuloma Also known as Lobular Capillary

Clinical Features: • Smooth or lobulated mass that may be pedunculated or sessile • Typically bleeds easily or spontaneously due to its vascularity • From pink to purple-red. May undergo fibrous maturation and resemble a fibroma • Frequently has an ulcerated surface • May exhibit rapid growth • Poor oral hygiene is typically noted and is believed to be a precipitating factor

Common Sites: • Gingiva ( ̴ 75 %). More common on the facial maxillary gingiva

Treatment: Conservative excision, which should extend to the periosteum in cases involving the gingiva. Removal of local factors (plaque) and hygiene instructions to decrease risk of recurrence

Prognosis: Good. Variable recurrence rate, but inferior to 15 %

Pyogenic granulomas frequently occur in pregnant women and develop from the 1st trimester to the 7th month of pregnancy. After pregnancy, some of these will resolve. Therefore, it is recommended to defer treatment until after gestation unless the lesion caused functional impairment or is an aesthetic concern for the patient.

Pyogenic granulomas may undergo fibrous maturation and resemble a fibroma. The oral pathologist may refer to this lesion as sclerosing pyogenic granuloma.

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Peripheral Giant Cell Granuloma

Clinical Features: • Red or red-blue lobular mass, may be pedunculated or sessile • May exhibit surface ulceration (up to 50 % cases) • May vary in size, but is usually less than 2 cm • May cause superficial resorption of the underlying alveolar , which may be visible radiographically

Common Sites: • Gingiva or edentulous ridge, slight predilection for the mandible

Treatment: Excision extending to the underlying bone. Scaling of the adjacent teeth and hygiene instructions to decrease the risk of recurrence

Prognosis: Good. Variable recurrence rate, between 10-20 %

Photo credit: Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2016). Oral and maxillofacial pathology (Fourth Some of the multinucleated giant cells edition.). St. Louis, Missouri: Elsevier. are highlighted by the white arrows and are set in a background of spindle cells with hemosiderin deposits and hemorrhage Peripheral Ossifying Fibroma

Clinical Features: • Firm gingival mass, may be pedunculated or sessile • Pink to red • May exhibit surface ulceration • May vary in size, but is usually less than 2 cm • May cause displacement of teeth and hypermobility of adjacent teeth

Common Sites: • Gingiva exclusively. More common on the maxilla • 50 % in the anterior region

Age/Sex Predilection: Peak predilection in 2nd decade. Females (2/3 cases)

Treatment: Excision extending to the periosteum. Scaling of the adjacent teeth and hygiene instructions to decrease the risk of recurrence

Prognosis: Good. Variable recurrence rate, less than 15 %

© Caroline Bissonnette

Lipoma are benign tumors of fat and constitute the most common mesenchymal . They are relatively uncommon in the head and neck region. Clinical Features: • Soft, smooth, circumscribed mass. May be pedunculated or sessile • Typically has a yellowish color, especially superficial lesions. Deeper lesions may not display any color change and will appear as pink nodules Common Intra-Oral Sites: • Buccal mucosa and buccal vestibule (50 % of cases) • Other sites include floor of mouth, tongue, lips • Some lesions in the posterior buccal mucosa may represent herniation of the buccal fat pad, and do not constitute a neoplasm Age/Sex Predilection: Adults. Male = Female Treatment: Surgical excision. Most lipomas will float in formalin and this should serve as a diagnostic clue. Prognosis: Excellent. Recurrence is rare and is not impacted by the histological variant at the exception of intramuscular lipomas. The latter have an increased risk of recurrence due to infiltration of the tumor in the adjacent muscle fascicles.

Photo credit: Pocket Dentistry Gross image of a . Lipomas will float in Formalin.

The lipoma shows a well- circumscribed collection of mature adipocytes. Many variants exist including fibro-lipoma, and . Granular cell tumors are benign mesenchymal tumors

Clinical Features: • Asymptomatic, slow-growing, sessile submucosal nodule • May be appear pink or yellow in color • May feel tethered to the underlying mucosa

Common Intra-Oral Sites: • Tongue (1/3 to 1/2 of cases), particularly the dorsal surface • Buccal mucosa

Age/Sex Predilection: Adults (mainly 4th through 6th decades). 2 F : 1 M

Treatment: Surgical excision.

Prognosis: Excellent. Recurrence is uncommon even in cases of incomplete removal.

© Caroline Bissonnette 400x

Congenital Epulis

Congenital epulis is an uncommon soft tissue tumor. It is also known as congenital granular cell lesion.

Clinical Features: • Pinkish-red, smooth, polypoid mass • May be detected in-utero by ultrasound

Common Intra-Oral Sites: • Almost exclusively on the alveolar ridge. Maxilla > Mandible • Anterior (Lateral, Canine) region more common

Age/Sex Predilection: Newborn. 9 F : 1 M Treatment: Surgical excision.

Prognosis: Excellent. No reported recurrences. May regress spontaneously after birth.

Photo credit: Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2016). Oral and maxillofacial pathology (Fourth edition.). St. Louis, Missouri: Elsevier.

The congenital epulis resembles a granular cell histopathologically, but they are consistently S-100 negative. S-100 is an immunohistochemical marker for neural differentiation. and Vascular Malformations

Hemangioma of Infancy Congenital Hemangioma Vascular Malformation Present at birth and persist Age Rarely present at birth Completely developed at birth through adult life. May only be- come noticeable in childhood NICH have a slight female Sex 3-5 F : 1 M predilection No predilection May be found in any part of Skin in the head and neck Skin the body Site region and trunk May involve the viscera Vascular malformations may be seen intra-osseously 1. Capillary malformation: Macular and red (i.e. port 80 % unifocal. Mature lesions Violaceous mass or plaque wine stain) appear as red, elevated, with surface telangiectasia. 2. Venous malformation: Clinical bosselated nodules that are May be surrounded by a pale Blue, soft Presentation firm on palpation. May rim. On palpation, NICH are 3. Lymphatic malformation: ulcerate. Deeper tumors may warm and the patient may Clear vesicles appear almost flat experience pain 4. Arteriovenous malformation : Variable depending on stage 5. Mixed lesions

Rapidly involuting congenital hemangioma (RICH) shows Rapid development during early regression and full Phleboliths and thrombosis Evolution first weeks of life involution by 14 months may develop in venous Noninvoluting congenital malformations hemangioma (NICH) follows growth of child and does not regress

Management will vary based Depends on the variant. Small on severity, localization and lesions may not require any symptoms. Small lesions Most do not require treatment. treatment Treatment usually have an excellent Some NICH may be treated Larger lesions may be treated prognosis and spontaneously by surgery with surgery and/or regress. β-blockers, cortico- sclerotherapy. Pre-operative steroids, pulse dye laser and embolization may be surgery have been used for necessary larger or symptomatic lesions 40% of patients will have Prognosis residual scarring, atrophy, Variable Variable telangiectasias Hemangiomas and Vascular Malformations Hemangiomas may be associated with certain conditions with systemic involvement: • PHACE(S) syndrome • Kasabach-Merritt phenomenon

Sturge Weber Syndrome is associated with the presence of a dermal capillary vascular malformation that follows the distribution of one or more branches of the trigeminal nerve. When the vascular malformation affects the V1 and or V2 © Caroline Bissonnette branches of the trigeminal nerve, the most common ocular involvement is glaucoma (30-60 % of patients). Patients also usually suffer from meningeal angiomatosis which result in intellectual disabilities and seizure disorders. Classic “tramline” calcifications may be visible on skull x- rays. Ocular involvement consists of glaucoma and vascular malformations.

Varices Varices are a common finding in the oral cavity of older patients and represent dilated and tortuous veins. The are typically multiple and occur predominantly on the ventral-lateral surface of the tongue. Solitary lesions can also present as bluish nodules or on the buccal mucosa or lips. As varices can become © Caroline Bissonnette secondarily thrombosed, they may be firm on palpation. A diascopy test can be used to reinforce the clinical diagnosis of a vascular lesion. Pressure is exerted on the lesion with a glass slide for 30 seconds to 1 minute. The lesion should blanch if it is vascular in nature as blood is expelled and vascular supply is interrupted. However, this test is not always reliable especially in the case of thrombosed vascular lesions which do not systemically blanch under pressure. Biopsy is indicated to confirm any suspicious lesion or for esthetic considerations. Neural Lesions Traumatic Solitary Schwannoma Neuroma Circumscribed Neuroma Age / Sex Any age, but more Adults Adults More common in young common in adults More common in 5th – adults Slight F > M 7th decade Clinical Smooth submucosal Smooth, slow-growing Smooth-surfaced, Smooth, well Features nodule. Onset may be asymptomatic papule or submucosal, circumscribed, preceded by surgery or nodule that is typically encapsulated nodule. asymptomatic, slow- trauma. Usually less than 10 mm in size Pain may be present, growing nodule associated with but is more common submucosal nodule. neuropathic symptoms with intra-bony lesions. Relatively soft to including pain Rubbery on palpation palpation. May have a yellowish hue Common Mental foramen area, Face (90 %). Common More common on the Skin. Common oral Sites lower , tongue. May oral sites include the tongue. May be intra- sites are the buccal be intra-osseous. hard palate, gingiva osseous mucosa and tongue. and buccal mucosa May be intra-osseous Treatment Excision with small Conservative excision Surgical excision Surgical excision portion of involved proximal nerve bundle Prognosis Recurrence is rare, but Recurrence is rare Recurrence and Recurrence and pain may persist malignant malignant transformation are rare transformation are rare

This submucosal, soft swelling of the retromolar pad was diagnosed as a neurofibroma following histopathological analysis

This photomicrograph represents a schwannoma. The alternating pattern of Antoni A (white arrow) and Antoni B (black arrow) is appreciable in this section.

Antoni A: Nuclear palisading, Verocay Bodies

Antoni B: Haphazard, loosely arranged cells

Photo credit: Goldblum, J. R., Folpe, A. L., Weiss, S. W., Enzinger, F. M., & Weiss, S. W. (2014). Enzinger and Weiss's soft tissue tumors. St. Louis: Elsevier/Mosby. Neural Lesions

This photomicrograph represents a neurofibroma. The cells are wavy, elongated and have a dark nucleus and are set in a background of collagen. Scattered mast cells are highlighted by the white arrows.

Neural Lesions and Associated Conditions

Multiple Endocrine Neoplasia Type 2B (MEN 2B) MEN 2B → Neuromas Multiple endocrine neoplasia type 2B (MEN 2B) is a rare genetic disorder transmitted in an autosomal dominant fashion. Patients with MEN 2B develop neuromas (including oral) which may represent the initial sign of the condition and can be detected during infancy. Bilateral neuromas at the commissures are characteristic of this condition. In addition to neuromas, patients with MEN 2B develop medullary thyroid in almost all cases. Prophylactic thyroidectomy is often completed in the first year of life. Pheochromocytomas occur in up to 50 % of patients with this condition. Most patients will also have a marfanoid appearance.

Neurofibromatosis Type I (von Recklinghausen Disease) Neurofibromatosis → Multiple (NF1) is a relatively common genetic disorder transmitted in an autosomal dominant fashion although up to 50 % of cases are caused by new mutations. A diagnosis of NF1 can be made if two or more of the following features are present: 1. ≥ 6 café-au-lait spots (> 5 mm pre-pubertal, > 15 mm post-pubertal) 2. ≥ Lisch nodules 3. Optic glioma 4. ≥ 2 neurofibromas or one plexiform neurofibroma 5. Axillary and or inguinal freckling 6. Presence of an osseous lesion (sphenoid or long bone cortex thinning)

Criteria established by the National Institute of Health (NIH) in 1987

Neurofibromatosis Type I (von Recklinghausen Disease) One of the most significant complications of NF1 is the increased risk (around 5 % cases) of developing a malignant peripheral nerve sheath tumor (MPNST). MPNSTs associated with NF1 have a lower 5-yr survival rate (42,9 % vs 58.2 %) compared to those occurring in patients without the syndrome. NF1 is also associated with other tumors including pheochromocytomas, , Wilms tumors and CNS tumors. of origin

Clinical Features: • Slow-growing, firm dome-shaped nodule • Usually asymptomatic, but may be associated with pain • Normal color or bluish-red hue • 75 % of oral are the vascular type (angiomyoma)

Common Sites: • Rare in the oral cavity. More frequent in the genitourinary tract (95 % in the female genitourinary tract) • Common oral sites include the palate, buccal mucosa, tongue and lips Age/Sex Predilection: None

Treatment: Complete excision

Prognosis: Excellent. Recurrence is rare

Leiomyoma Leiomyoma – Vascular Variant

Photo credit: University of Washington Photo credit: Goldblum, J. R., Folpe, A. L., Weiss, S. W., (https://dental.washington.edu/oral- pathology/case-of-the- Enzinger, F. M., & Weiss, S. W. (2014). Enzinger and month-archives/com-march-2013-diagnosis/) Weiss's soft tissue tumors. St. Louis: Elsevier/Mosby. Benign tumor of origin. More commonly affects the heart. However, extra-cardiac cases have a predilection for the head and neck region.

Adult Rhabdomyoma Fetal Rhabdomyoma Age / Sex Adults and seniors Young children mostly. 75% Male May occur in adults 75% Male Clinical Submucosal mass, may appear Submucosal mass Features multinodular May cause airway obstruction Common Most common extra-cardiac site: pharynx, Face and more specifically the pre- Sites larynx and oral cavity auricular area Common oral sites: Floor of mouth, base of tongue and soft palate

Treatment Complete excision Complete excision Prognosis Variable recurrence rate reported in the Variable recurrence rate reported in the literature literature

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Other Entities Many other benign soft tissue lesions may be encountered in the oral cavity, but will not be discussed in this course. These include, but are not limited to: • Inflammatory Papillary Hyperplasia • Oral Focal Mucinosis • Fibrous • • Myofibroma • • Ectomesenchymal Chondromyxoid Tumor • Melanotic Neuroectodermal Tumor of Infancy • Osseous and Cartilaginous • • Proliferative Myositis Part II Soft Tissue

Introduction

You have detected a lesion in your patient's mouth. What should you do? You may decide to refer immediately your patient to a specialist (Oral Pathologist, Oral and Maxillofacial Surgeon) or you may decide to manage the pathology. There is no perfect algorithm for the management of oral lesions. As a general rule, lesions showing no improvement or resolution within 2 weeks should be biopsied. Part II Soft Tissue Biopsies

Introduction

As mentioned in the previous slide, there is no perfect algorithm to determine the best practice for a particular case. The clinician must evaluate An unaided human eye all aspects of a lesion as well as the patient’s can discern things as small as 0.1 mm. associated symptoms. A provisional clinical diagnosis will aid the clinician in determining the With a conventional appropriate course of action. Potential surgical optical microscope, risks must also be evaluated and discussed with particles as small as the patient. Follow-up can be an acceptable plan 0.2 µm (0.0002 mm) for small, stable, asymptomatic lesions (i.e. can be observed. fibroma). However, the clinician must be cautious as some benign tumors and low-grade can be mimics.

A patient may also decide to refuse the procedure. In this case, the practitioner must thoroughly inform the patient that a definitive diagnosis cannot be made and discuss alternatives (follow-up, referral to a specialist, etc.).

Prior to proceeding with the biopsy, the clinician must first carefully evaluate the patient's medical history and inform them of the clinical diagnosis of the lesion.

A medical consultation may be necessary prior to proceeding if the patient's complex medical history precludes a surgical intervention.

The patient must be advised of the risks related to the surgical intervention and an informed consent must be obtained. Possible esthetic defects should be mentioned when biopsies are done in the perioral region and lips. Although most biopsies can be carried out under local anesthesia, the clinician may discuss sedation options with the patient (i.e. oral sedatives, inhalation sedation and conscious intravenous sedation). Incisional vs. Excisional • Incisional biopsies of the most representative area of the lesions are recommended when the histopathologic diagnosis has an impact on the treatment. Therefore, all suspected malignancies should first be diagnosed with an incisional biopsy.

• Care must be taken to biopsy the most representative area of a lesion. A portion of the normal appearing periphery should be included if this approach does not compromise on the sampling of diagnostic tissue.

• Multiple incisional biopsies should be taken if the lesion is heterogeneous or extensive. They should be appropriately identified based on the site of procurement either with the placement of different sutures or by individually placing specimens in separate formalin bottles. • Many small soft tissue lesions can be excised completely and submitted for histopathologic examination. The dentist doing the procedure should take caution if: • Challenging anatomical landmarks are in the vicinity (i.e. Parotid papilla, Wharton Ducts, Greater Palatine Artery, Mental Foramen, etc.) • The post-op defect requires reconstruction • Depending on the extent of the lesion, some gingival biopsies may lead to exposed tooth roots. Patients should be advised of this possibility prior to the biopsy.

• General indications for incisional biopsies: • Suspected • Large lesion (> 1 cm) • Hazardous anatomical structures in the area

• General indications for excisional biopsies: • Small lesions (< 1 cm)

• Depending on the clinicians level of experience in surgical procedures, larger lesions with a high suspicion for a benign or non-neoplastic process (i.e. fibroma, mucocele, etc.) may be completely excised without a prior incisional biopsy.

• Multiple incisional lesions of one large lesion may be taken especially if the appearance is heterogeneous. In this case, the clinician should clearly identify the specimens in regards to the site of sampling. Recommended Material

Minnesota Retractor Syringe Scissors

Needle Holder Scalpel Blade Handle Adson Anatomical Tissue Pliers (Ideally without fine teeth)

Hemostatic Forceps Scalpel Blade Topical Skin Adhesive

Gauze

Photo credits: The Surgical Room Local Anesthesia • Local anesthesia can be easily achieved with perilesional injections (approximately 1 cm away from planned incisions). In most instances, less than 1.8 mL (1 carpule) is necessary to achieve complete analgesia. Block anesthesia techniques may also be used. Common anesthetic agents used include: • Mepivacaine HCl. 3% • Lidocaine HCl 2% with Epinephrine 1:100,000 • Articaine HCl 4 % with Epinephrine 1:100,000

• Perilesional injections with a hemostatic agent (Epinephrine) may be beneficial for local bleeding control.

• Intralesional injections should be avoided as this causes vacuolization of the cells. Conventional Blade Excision

It is recommended to use stainless steel blade for soft tissue biopsies. Incisional and excisional biopsy techniques are outlined in the following slides.

Incisional biopsy: Incisional biopsies are usually in the shape of an ellipse. It is recommended to include the interface between the lesion and the normal adjacent tissue when possible. The outline of the wedge is incised with a no.15 at the desired depth. A no.12 curved blade may be used depending on the location of the lesion. The base is then dissected using the scalpel blade or with surgical scissors. The specimen must be placed as soon as possible in the formalin bottle.

Photo credit: Contemporary Oral and Maxillofacial Surgery Conventional Blade Excision

Excisional biopsy: The clinician must first evaluate if the complete excision of the lesion may cause impairment of oral function. If the ablation of the entire lesion causes significant complications, an incisional biopsy is preferred. Depending on the histopathological diagnosis, no further surgical intervention may be needed.

Excisional biopsy outline incisions should be 1 mm – 3 mm from the lesion's margins. In absence of anatomical hazards, care must be exerted to dissect the lesion at the base to Photo credit: Contemporary Oral and insure complete removal. Maxillofacial Surgery

Punch Biopsies Tissue punches are regularly employed in dermatology and may be used for intra-oral incisional or excisional biopsies depending on the size of the lesion. They are available in a variety of diameters. Nevertheless, a wedge biopsy remains the preferred technique.

Punch biopsy technique:

Pressure is exerted perpendicularly with the punch on the mucosa. In a rotating fashion, the punch penetrates the soft tissue to the desired depth and then removed. The core of tissue is then separated from the base with a scalpel Photo credit: The Surgical Room blade or scissors. Re- approximation of the wound margins may be more difficult than with an elliptical shape. Lasers Carbon dioxide (CO2) and diode lasers have gained in popularity in the past years and are now found in many dental practices. Due to their hemostatic properties, lasers are commonly used for surgical procedures. However, they cause cautery artefact (necrosis) at the margins of the specimen. In small biopsies, this may lead to considerable difficulties for the pathologist rendering the diagnosis. The clinician must consider this factor when determining which tools will be used for the biopsy. Lasers should be avoided when precancerous or malignant lesions are suspected. The clinician using a laser should enlarge biopsy margins by 0.5 mm to avoid thermal artefact in the area of interest. This measure will also enable the pathologist to comment on adequacy of excision when necessary. Given the appropriate setting, lasers remain useful tools in the surgical instrumentation. Cautery Artefact

Arrows highlight necrosis at the margins. Cautery artefact is seen when lasers or electrosurgery is used.

Photo Credit: Jodi Speiser, MD. Dermatopathologist at Loyola University Health System

Hemostasis and Wound Closure • When possible, primary wound closure is recommended. If the defect is deep and implicates different tissue layers, closure of each layer individually with resorbable suture material is warranted. • When the defect is large, undermining the mucosa to separate it from the submucosal tissues will reduce tension when reapproximating the margins. • Sutures should be placed 2 mm – 3 mm away from the incision margins. They should also be at short intervals when closing a wound on a tongue as there a more inherent movements, which could cause the primary closure to fail. Excess suture should be cut close to the knot ( ̴ 2 mm) to reduce potential discomfort for the patient. • Braided, absorbable sutures such as polyglactin 910 (Vicryl) sutures will support the wound for up to 3 weeks and are generally well tolerated by the tissue. Hemostasis and Wound Closure Chromic Gut may also be used, but undergo enzymatic degradation more rapidly. They remain an adequate suture material for small biopsies as they ensure sufficient closure for the wound. Furthermore, as they do not last as long, patients experience less irritation or discomfort. Polyglactin 910 (Vicryl) are also available in a format (Vicryl Rapide) which has a comparable performance to chromic gut sutures. Silk sutures are another commonly used material. Although studies have shown that they are not associated with an increased bacteremia at the wound site, they typically illicit a more prominent host inflammatory response. This may be associated a certain delay in healing. However, as they are non-resorbable, wound support is prolonged. In the oral cavity, 3-0 or 4-0 caliber sutures are used. 5-0 caliber sutures should be used for more esthetic areas such as the lips. Biopsies on the hard palate and gingiva will heal by secondary intention. With both primary closure and open wounds, the clinician should insure that hemostasis is obtained before dismissing the patient. Once bleeding has stopped, a topical skin adhesive such as Histoacryl may be used to cover the site. It must be applied as a thin layer. If it is applied as a thick coating, its resistance to dislodgment is decreased. Patients must be advised that biocompatible adhesives have a variable hold in the oral cavity. They must not be alarmed if it is lost. Depending on the site of biopsy, periodontal dressings including Coe-Pack or acrylic splints may also be made to increase the patient's post-operative comfort.

Post-operative Considerations Post-operative recommendations given to the patient should include: • Dietary modifications: Soft, lukewarm to cold foods should be favored to avoid patient discomfort. • Avoiding spitting and using straws for the first 48 h. • Patients should avoid smoking, drinking alcohol or using recreational drugs until the site has completely healed. • For gingival biopsies, patients should avoid brushing the site for the first 5-7 days following the procedure. • As with extractions, gauze should be given to the patient even when sutures are placed. The patient should be informed on how to apply pressure to the site in the event of post-operative bleeding.

A post-operative follow-up appointment should be scheduled 1 to 2 weeks after the procedure to insure appropriate healing of the surgical site and to discuss biopsy results with the patient. Biopsy Pearls • Tissue stabilization is key to the success of the biopsy. Sufficient tension in the tissue will facilitate incisions and reduces bleeding by causing vasoconstriction. • The use of high-volume suctions should be avoided as much as possible. Although suction artefact is not ideal during histopathological examination, losing the specimen in the pipes is worse. The assistant can use 2x2 gauze to absorb blood in the surgical field. • Starting with the inferior incision will prevent bleeding onto the surgical site. • If minor salivary glands are exposed during the biopsy, they should be removed to decrease the risk of mucocele formation. • Tissue forceps with teeth can cause tears in the tissue and should be avoided. The clinician should handle tissue with a delicate pressure to prevent clamping/crushing artefact. A traction suture may be helpful. • The lips and floor of mouth are well vascularized areas. Just as with vascular lesions, the clinician must be comfortable in managing increased bleeding. • Although it is generally safe to proceed with most biopsies on patients taking either anti-coagulant and/or anti-platelet therapy, patients must be warned of the increased risk of hematoma formation. Delayed post- operative bleeding can also be a complication. • An INR ≤ 3.5 is recommended for patients taking Warfarin • Biopsies can done on patients taking oral anticoagulants including direct thrombin and XA inhibitors. Local hemostatic measures are recommended. Contact the patient's physician if necessary.

Tissue Orientation • Incisional biopsies do not need to be oriented. • A dentist may decide to orient a completely excised specimen to verify if all lesional tissue has been removed. However, it is not mandatory to do so. Many soft tissue lesions will not recur even if they were not completely excised. Excisions of malignant tumors are always oriented by oncologic surgeons. • If sutures are used for orientation or traction, the knot should be placed away from the tissue. Securing the knot tightly on the tissue may lead to tearing while attempting to remove it during processing. (See below) Tissue Orientation For optimal tissue orientation, two sutures should be placed on the tissue; one on the anterior or posterior margin and one on the superior or inferior margin (medial/lateral). The sutures must be distinct (different colors or different lengths) and this information must be relayed to the pathologist.

Thin tissue samples should be placed on a humid piece of cardboard ( facing up) to avoid curling of the specimen. Thereafter, they can be placed in the formalin bottle. This facilitates tissue orientation by the histotechnician, which decreases the risk of obtaining cross-sections of the specimen. Optimal embedding of the tissue helps the oral and maxillofacial pathologist render an accurate diagnosis.

Fixation and Transport Solutions • Appropriate fixation is one of the most important steps to obtain high quality histological sections. • The most common fixative employed in pathology for routine evaluation is • 10% neutral buffered formalin. • The standard minimum ratio of tissue to formalin (fixative) is 1 : 10. In the event the sample of tissue is large, it is recommended to use a larger container, which will be able to hold more formalin. Insufficient formalin will result in suboptimal fixation of the sample. • Formalin should be discarded as a hazardous Photo credit: Statlab material past expiration date or earlier if precipitation is observed. Fixation and Transport Solutions To prevent extensive freeze artefact:

• Place specimen in the formalin containers with your patient inside the office overnight. This will fix the tissue. • The next day, add 70% alcohol (ethyl or isopropyl) to the specimen bottle so that it is 3/4 full before sending it.

What about Michel’s Solution? Michel’s solution is a transport medium. It cannot be used as a fixative and is not indicated for examination of specimens under light microscopy. Michel’s solution must be used when immunofluorescence studies are necessary. Specimens in Michel’s should be sent immediately as ideally they should be processed a maximum of 5 days after the procedure. Before being sent, it can be stored in the refrigerator at 39.2 ºF (4 ºC).

Photo credit: Statlab

Conditions for which immunofluorescence studies are necessary or useful: • Mucous Membrane • Vulgaris • • Chronic Ulcerative

Therefore, formalin is the fixative solution of choice for soft tissue biopsies. Tissue samples should be placed as soon as possible in the fixative solution to prevent cell autolysis. Author Caroline Bissonnette, DMD Post-Course [email protected] SMS Director Christine Harrington, DDS Questionnaire [email protected] • Answer each question ONLINE (link provided on SMS website) SMS Program Manager Answer 12 of 16 questions correctly to pass Sydney Fisher, MPH • [email protected] • Answer post-course survey questions and click “Finish” • Deadline is November 22, 2018 4:30pm SMS Program Assistant Nick Kotlar, BS [email protected] 1. The standard minimum ratio of tissue to formalin (fixative) is: a) 1:2 b) 1:4 c) 1:10 d) 1:20 2. Identify the false statement. a) An incisional biopsy is recommended when a malignancy is suspected. b) CO2 lasers are the ideal instrument for biopsies as they contribute to hemostasis and do not cause any artefactual distortion. c) An excisional biopsy is recommended for a slow-growing, pink, smooth, pedunculated nodule measuring 5 mm x 5 mm on the buccal mucosa d) The specimen should be placed in a fixative solution as soon as possible after excision. 3. Which lesions can appear yellow clinically? 1. Neurofibroma 2. Fibroma 3. Lipoma 4. Granular cell tumor

a) 1, 3, and 4 only b) 3 only c) 1 and 2 only d) 1, 2, 3, and 4 4. A varix will always blanch with the diascopy test. a) True b) False 5. Which lesion occurs exclusively on the gingiva? a) Pyogenic granuloma b) Peripheral ossifying fibroma c) Schwannoma d) Fibroma 6. Which tumor is associated with multiple endocrine neoplasia (MEN) type 2b? a) Neurofibroma b) Solitary circumscribed neuroma c) Neuroma d) Astrocytoma 7. Fibromas and giant cell fibromas are histologically identical and are differentiated only based on their clinical appearance. a) True b) False 8. Which statements are false regarding congenital epulis? 1. They show a striking male predilection (9M : 1F). 2. They are more common in the posterior mandible region. 3. Although complete excision is achieved, the recurrence rate is high. 4. A congenital epulis usually develops in the 2nd decade of life.

a) 1 and 3 only b) 2, 3, and 4 only c) 1, 2, and 3 only d) All statements are false 9. Which conditions are associated with hemangiomas? a) and Neurofibromatosis Type I b) Multiple Endocrine Neoplasia (MEN) type 2b and Kaposi c) Sturge Weber Syndrome and Kasabach-Merritt phenomenon d) Granulomatosis with Polyangiitis (Wegener’s) and Henoch-Schönlein Purpura 10. Which statement is true regarding Michel’s Solution? a) Michel’s solution can be used to fix any tissue as long as it is processed by the pathology laboratory within 7 days of procurement. b) Michel’s solution is the appropriate transport solution for fresh tissue sent for direct immunofluorescence. c) Regardless of the clinical diagnosis, specimens must always be sent in Michel’s solution. d) Michel’s solution cannot be stored at 39.2 oF (4 oC). 11. Which measure during the excisional biopsy of a peripheral ossifying fibroma can help reduce the risk of recurrence? a) Copious irrigation with Chlorhexidine gluconate b) Extending the excision to the periosteum and scaling the adjacent teeth c) No additional measures are needed as the peripheral ossifying fibromas never recur d) Obtaining primary closure of the surgical site 12. You are considering orienting your biopsy. Which of the following placement and choice of sutures is optimal? a) One long suture anteriorly and one short suture posteriorly b) One long suture anteriorly only c) One blue suture medially and one blue suture anteriorly d) One short suture posteriorly and one long suture superiorly 13. Which are true regarding leiomyomas? 1. The show a strong predilection for the head and neck region 2. Approximately 75% of cases in the oral cavity are angiomyomas 3. Clinically, the may exhibit a bluish hue 4. A common oral site is the gingiva

a) 1 and 3 only b) 1, 2, and 3 only c) 2, and 3 only d) All statements are true

The following 3 questions are regarding the case presented below.

A 38 female presents to your dental clinic with the lesion in this picture. She reports she is asymptomatic and has noticed that the lesion has been growing slowly for the past 8 months. She has not seen a dentist in 10 years. A radiograph in of the area shows no bone involvement. Photo credit: www.contempclindent.org. Authors: Satheesh Mannem, Vijay K Chava 14. What is the most probable diagnosis in the following list? a) Peripheral Ossifying Fibroma b) Pyogenic Granuloma c) Leiomyoma d) Peripheral Giant Cell Granuloma 15. You have discussed your clinical impression with the patient. What is the following step you should recommend to your patient? a) Follow-up b) Biopsy c) Immediate referral to endocrinology to evaluate for hyperparathyroidism d) The lesion is benign. No further treatment or follow-up required. 16. What is the estimated recurrence rate of the lesion depicted in the case? a) 0% b) 5% c) 10-20% d) 40-50% End of Test