Transcribed by Anam Khalid Monday, July 7

th
, 2014

1
[Diagnosis and Treatment of Oral Diseases] [Lecture #5] [Surgical Oral
Biopsy Technique] by [Dr. S. Shah]

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

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

[2] [Characteristics of Suspicious Lesions]
[Dr. Shah] Characteristics of suspicious lesions. So, erythroplasia. What does
erythroplasia mean? It means theres a red component. Okay? So, if the lesion is
totally red, thats called erythroplakia. Or has a speckled red appearance,
erythroleukoplakia, where you can have a red and white component. Any redness is
suspicious. Okay? So, ulceration, if a lesion is ulcerated or presents as an ulcer, thats
a suspicious finding as well. Long duration, if a lesion has persisted for more than
two weeks with no change even though you tried to change, you know, some biting
habit or some sharp or broken tooth or something along those lines. Fast growth
rate, something is growing pretty quickly or increasing in size pretty quickly.
Bleeding, if something bleeds on gentle manipulation, thats not a good sign. Okay?
As you should know, tumors and malignancies, angiogenesis, they have a supply of
extra blood vessels. So these things bleed easily. And theres another word for that:
friability. Friability. The tissue falls apart and bleeds easily. Induration is another
characteristic of suspicious lesions. Induration is when the lesion and the
surrounding tissue is firm to the touch. So, we talked about this when I was talking
about the lip cancers, remember? I said when you feel the lip, it feels soft and all of a
sudden, youll feel a really firm area that feels fixed? Thats called indurated. Okay?
And then fixation means when something doesnt move. Its attached to the adjacent
structures. So these are your characteristics of suspicious lesions. Yes, sir?
[Student] That top, when you want to say erythroplakia, it says erythroplasia
Transcribed by Anam Khalid Monday, July 7
th
, 2014

2
[Dr. Shah] Okay, so, erythroplasia just means its a general term for redness. Okay?
A red component. Erythroplakia is a flat red lesion. Okay? So its just a little bit of
terminology there. Okay. So characteristics of suspicious lesions.

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

[5] [Incisional Biopsy Technique]
[Dr. Shah] Incisional biopsy technique, heres just a little basic diagram to show
you. Desirable is narrow and deep, youre going, you know this is epithelium and
this is connective. Youre going deep. Here, this is broad and shallow so its better to
go narrow and deep. Okay.

[6] [Biopsy Site Selection: Red Area]
[Dr. Shah] Now Im going to go over some lesions and show you what is the best
site to biopsy. Okay? So these are representative sites or worse looking areas. So
here you have a lesion, right? On the lateral border of the tongue. Its red and its
white and its ulcerated in some areas. This is an actual ulcer, were missing
Transcribed by Anam Khalid Monday, July 7
th
, 2014

3
epithelium. Theres some white changes. Theres some red areas. So, you know,
whats one of the better sites to biopsy here? I circled this because I would go for
this red area here. Okay? So red is better to biopsy than white and its considered
worse looking.

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

[Student] -- Shouldnt that be like [unintelligible] symptoms?

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

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

[9] [Biopsy Site Selection: Velscope and T Blue]
[Dr. Shah] Okay, then theres something else, Dr. Kerr, who is my colleague, you
know, hes an oral cancer and pre-cancer expert and hes going to be giving you a
lecture pretty soon. We have these two special tests, I dont know if any of you have
ever heard of these: Velscope and Toluidine Blue. Anyone? Okay, theyre going to go
into a lot more detail about this shortly. Okay? So do not panic, you know, if you
dont know what this is. Right now, Im just barely covering it. Velscope is a special
light that you use and wherever you see black areas, those are suspicious areas that
Transcribed by Anam Khalid Monday, July 7
th
, 2014

4
you should biopsy. Okay and T blue is a blue stain that wherever it stains blue,
darker blue, those are suspicious areas that you should biopsy. Okay? So we use
these tests in the oral medicine clinic and in our BlueStone Center for oral cancer
and pre-cancer. Okay, so these are dark areas, so in this lesion, these are good areas
to biopsy. Okay? This is T blue staining; wherever its positive might be good areas
to biopsy, okay?

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

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

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

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

[12] [Biopsy Studies]
Transcribed by Anam Khalid Monday, July 7
th
, 2014

5
[Dr. Shah] I talked about biopsy site selection but now I want to go over the actual
process of doing a biopsy. Okay? And this is important and you guys should when
you get into private practice be doing biopsies. I have to tell you that, you know,
most people just send it straight to an oral surgeon or to an oral medicine, oral
pathologist expert. But you can do these things and you should, you know? Again,
remember, DDS, doctor of dental surgery. Surgery. We dont just have to do fillings
and crowns and bridges. These things can really affect patients lives. And you can
really make a difference. Alright, so now I want to go over the procedure but with
that said I have to tell you that you guys dont generally get a lot of opportunities to
practice biopsies at this school because it goes to the oral surgeons or it goes to
faculty such as myself. But I want to point something out to you; I do run two honors
programs, third year and fourth year. And my honors students get to do biopsies in
my clinic so if its something that youre interested in in the future, keep that in
mind. Okay? But otherwise, you dont get much experience, unfortunately, with
biopsies. Alright. So this is the procedure. This is the equipment that you need to
have. You have to have a blade handle with a number 15 blade. Im going to tell you
theres those disposable blades out there and each person has their own preference.
I hate disposable blades because then I never find the blade sharp enough. Okay? So
I like the steel handles and the number 15 blade on it. Okay. Then you need a soft
tissue forceps to hold the tissue. It should have some teeth on it, something to give
you grip of the tissue. Now, with that said, it shouldnt have, you know, really sharp
or too many teeth where youre just crushing and destroying the tissue. Okay, then
youre going to need, you probably should numb your patient. So, you should have
some local anesthetic solution and syringe. Okay, retractor. Youll need something to
hold the tissue. You need a suction source and a surgical suction tip. Anytime, we do
a biopsy, we dont use the normal, you know, suction evacuator or whatever. You
need an actual surgical suction tip. Theres in the school the green one and the blue
one. Okay? We like the blue one because it has a narrower tip. So tell me, why, if Im
doing a biopsy do I want a surgical suction with a narrow tip? Simple reason, really.
Yea, I dont want it to suck up my 4 or 5 mm biopsy and believe me, its happened
before. Okay? And you dont want that thats a hard one to explain to patients so
you really dont want that to happen. So, the surgical suction tip has a really small
opening, okay? Gauze. Youre going to need gauze for hemostasis, for drying the
tissue, and for retraction. Sutures can be used traction means holding the tissue
and obviously, closure. If indicated I have to tell you that for many oral biopsies,
we dont even suture. I think I barely suture 10% of all the biopsies I do. Okay?
Because a lot of them are punches and if you do a punch, you get a nice round hole.
You cant suture that together; you dont have edges to suture together. And most
oral biopsies are so superficial that gauze pressure can lead to hemostasis so you
dont really have to suture it and they heal quite well. Okay? But occasionally, you
know, when were doing a large soft tissue lesion or something along those lines,
you do have to suture it. And again, when you go in the oral surgery, youre going to
learn more about this but sutures, its by preference, really. They come in different
materials, they come in different thicknesses. Some of them are resorbable, some of
them are not. I personally prefer threo silk. I love silk. Silk is easily maneuverable.
Okay, chromic gut and Vikril (?), theyre really thick and theyre really bulky and
Transcribed by Anam Khalid Monday, July 7
th
, 2014

6
theyre hard to make a good knot. And I think you get much better results with silk.
Okay? So, again, when you do oral surgery youre going to find what you like and go
there. Also, Ill tell you one more thing: resorbable sutures, I really dont like from a
pathology point of view because what happens, and Ive seen the tissues under the
microscope, they dont fully resorb and you get a huge inflammatory reaction
around it and a bump and Ive seen these biopsied and under the microscope where
I can see suture bits and then inflammatory cells around it. So I truly believe and
another great reason to use silk is my patient has to come back a week later for
suture removal and that way I can really keep track of them and give them the
results. So if you think about it, silk is really a great option. Theres only 1 downfall,
who knows what it is? And thats a real downfall at this school here its really
expensive, yea. Thats the only issue that I see for silk, okay? Lets see, so we talked
about sutures, okay. And then you also have to have, obviously you have to have a
bottle to put the biopsy in. specimen bottle containing formalin. It should be labeled
and there should be a sheet with it that you put the name and the clinical
information on. Okay?

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

[14] [Preliminary Steps]
[Dr. Shah] Preliminary steps. Okay, so now lets say you know you decided that you
want to do a biopsy. You should know the patients medical history. Never treat a
stranger. Im sure youve heard that rule before, or you will. You have to know what
youre doing and who youre dealing with and what their medical history is. Okay?
So make sure the patient has no coagulopathy. What does coagulopathy mean?
Transcribed by Anam Khalid Monday, July 7
th
, 2014

7
Problems with clotting. Okay, so, obviously, a biopsy is a surgical procedure. You
want to make sure your patient is able to clot so you I probably would think long
and hard before I decided to do a biopsy on a patient thats on Warfarin, or
Coumadin, or Plavix or one of those blood thinners or high-dose aspirin. You really
have to think about that because the worse thing you can do is try to biopsy
something and then cause a bleeding issue and cause harm, right? We always take a
blood pressure before we do a biopsy. Always. Doesnt matter if the patient says
they feel fine, doesnt matter if the patient is young and healthy looking. You always
take a blood pressure. You should always take a blood pressure, its not always what
happens, but you should. Okay, obtain informed consent. Okay? This is a procedure
that you are doing that requires consent. You have to have the patient sign a consent
form. And on the consent form, you have to specifically write what youre doing. So
the school has these generic consent forms and the bottom line says treatment. You
should not have your patient ... your patient should not be signing that unless on the
bottom youve written specifically what youre doing incisional biopsy of left later
tongue, excisional biopsy of nodule on cheek. Whatever. Okay? And then that should
be explained to the patient and then the patient signs that. If you have a form where
you have not written anything on the bottom and there is a lawsuit or a case, that is
malpractice right there. Okay? The patient can easily say I never consented to that, I
dont know what I signed. It doesnt say anything here. I thought I was just getting
dental work. Okay? So you have to make sure that you have that written on the
bottom. Okay? So once youve got the medical history, blood pressure, consent, now
we can actually, you know, get somewhere get started. But first, before you do
that you have to actually plan out how youre going to do it. You have to have an
assistant, somebody whos going to help you. How are they going to retract the
tissue and suction. Okay? Then once youve figured all that out, youre ready to go to
local anesthesia. We do use a little topical benzocaine, okay? And then were ready
to give our anesthesia. Okay.

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

[16] [Anesthesia for Oral Biopsies]
Transcribed by Anam Khalid Monday, July 7
th
, 2014

8
[Dr. Shah] Anesthesia for oral biopsies. Now were ready. How do you do the
anesthesia? We usually do, almost always I should say, local infiltration and we want
use the least amount of lidocaine with epinephrine. For most oral biopsies, a quarter
to half a carpule is all we need; I almost never use more than half a carpule of
anesthetic, maybe for a tongue biopsy or maybe for something really big or along
those lines. But other than that, a quarter to half a carpule is plenty for any oral
biopsy. Okay? So, let me ask you a question: have you guys, probably not, but I have
to ask anyway, done anything with anesthesiology yet? Do you know anything about
blocks or local infiltration? You guys havent done the thing where you do injections
on each other yet, right? Okay. Alright. That fun is coming soon. Local infiltration
means that youre injecting right around the lesion, okay? Theres something called
blocks. A block is were injecting into a nerve opening and you numb the whole
nerve. So when we do dental work we normally do blocks, especially if were doing
mandibular teeth, theres something called the mandibular block or inferior alveolar
nerve block, it numbs that whole side and the side of the tongue and that side of the
lip and things like that. Its the entire nerve. Okay? But when we do oral biopsies,
were not doing blocks; were going right around the lesion and numbing that area.
Can you think of why we might do that instead of numbing the whole area? Just
think about this, why would you just do that area instead of numbing that whole
whole block? Anyone? Okay, well think about yea

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

[Dr. Shah]Not quite. Okay, think about the vasoconstriction, okay? One of the
things is that the epinephrine in the anesthetic helps with vasoconstriction or
controlling bleeding at the site of biopsy so thats why I want to do the infiltration
right around where Im cutting because its numb right where Im cutting and it
helps control the bleeding right where Im cutting, okay? Alright. Never inject
directly into a lesion, you always inject around the lesion were going to be cutting.
You dont go straight into the lesion, that can distort the tissue and youre not
numbing the area where youre going to cut. Although, slowly over time it does kind
of diffuse anyway but still. Inject slowly so as not to distort the tissue. When you
start doing dental injections youll see that you dont want to inject too fast or the
whole area just swells up, okay? And its really uncomfortable for the patient and it
doesnt diffuse like it should. So you inject slowly. Okay. Inject at multiple points
surrounding the lesion. I want to tell you that there are two schools of thought for
this. Some people if they have a lesion they just inject under it at an angle and let it
diffuse, so just one injection, which is more pleasant for the patient, to tell you the
truth. However, other people, including myself, I like to do the four-point, where I
actually go four points around it. It is four injections for the patient, its a little
uncomfortable in the beginning but I know the area is numb and I know my entire
area that Im going to biopsy, Im going to get vasoconstriction and I prefer to do
that. But youll see when you do this what you prefer, okay? And its important to
test the area before proceeding to biopsy. After you did the anesthesia, you really
want to like I usually take a perio probe and test the area and then test the
Transcribed by Anam Khalid Monday, July 7
th
, 2014

9
surrounding tissue and ask the patient if they feel different. Thats usually how I test
it. You could use an explorer but I would advise against it because it has a sharp
point and youre creating little punctate holes and bleeding. So I like to use a perio
probe. Okay. So now, after weve done the anesthesia, now were ready to do the
biopsy. Its show time. Its time to perform the biopsy.

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

[18] [Post-biopsy Steps]
[Dr. Shah] Now what? Its not over, we dont just throw the tissue and the bottle,
Im done, Im out of here. You really have to that patient is your responsibility.
And in fact, the worst part is this part where you have to control bleeding and make
sure your patient is okay before you let them go. Okay? The biopsy can be quick; I
mean I can do a biopsy from start to finish in less than five minutes. Its the
hemostasis and the issue afterwards that you have to deal with. Okay, so most of the
time in a normal healthy patient, you can get hemostasis just with gauze pressure.
Transcribed by Anam Khalid Monday, July 7
th
, 2014

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

[Student]--[unintelligible]

[Dr. Shah]--Okay, so youre sort of on track. Were really waiting for healing and re-
epithelialization, which takes about two weeks. Okay? So two weeks is a good
amount of period to wait to see if theres any signs of infection or to allow for
healing, okay? So normally we wait two weeks. However, if you have a patient that
lets say I put my silk sutures in, Ive got to see them in one week to remove those
sutures, or lets say you have a patient that youre really worried about for the
results or youre really worried during the procedure they had a lot of bleeding or
something else, I might call them earlier for like one week. I would probably never
do a follow-up earlier than one week unless something went wrong during the
biopsy procedure and I had to see them earlier. Okay? And then another reason at
the school we like to do a two-week follow-up is to ensure, of course, when you do a
biopsy when the patient comes back you want to give them the results of the biopsy,
right? So you want to make sure that the lab that you sent it to has sent you a report
so that you can give the results to the patient when they come back. So two weeks is
a good amount of time to allow, you know, to send to the lab for pathologist to sign it
out for it to come back. And here, you know, as Im one of the pathologists, Dr.
Phelan whos going to be lecturing to you on Thursday who is the chair of the
Transcribed by Anam Khalid Monday, July 7
th
, 2014

11
department and my boss, is the other oral pathologist, okay? And so for us, the turn
around at the school is very fast. If you do a biopsy, in about two or three days the
report will be there, you know, we work pretty fast and good like that. But some
other places may take you longer, okay? So you want to allow time for biopsy
results.

[19] [Submitting the Biopsy]
[Dr. Shah]
Okay, then submitting the biopsy. Okay, so youve taken care of your patient, your
patient has a follow-up appointment; the patient is leaving and gone, okay. Now,
what do you do? Youve got to submit the biopsy, so again, you want to make sure
the bottle is labeled with the name of the patient, the date, and biopsy site. You want
to fill out the form, theres a form that goes with every biopsy bottle. And the form
asks you, you know, what you think it was, where the site was and a bit about
medical history. You want to put all important information and the specific site of
the biopsy and you want to submit any clinical photos or x-rays. Its really a good
thing and youll note when you have a patient, now these cellphones and mobile
phones have really good cameras. So you dont have to buy those fancy clinical
cameras and expensive cameras. But its really good practice to when you see
something to take pictures of things. And it really helps if you send it to the
pathologist to help make the diagnosis, okay? So, did someone have a question? I
thought I saw somebody raise a hand back there yea?

[Student]--[unintelligible]

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

[20] [N/A]
[Dr. Shah] Okay, so heres a picture of a biopsy bottle, okay? This has got 10%
formalin in it and you have these biohazard bags. These bottles should be placed
inside of this bag, okay? And then these bags, these arent the bags and bottles we
use at the lab actually. But the bags that we use have a pocket in the front and then
they have a zipper component inside the bag. The pocket in the front is for the
forms, okay? We keep the forms separate from the bottle. Many times the bottle
opens or leaks so that the form doesnt get ruined or smeared or destroyed or
become illegible. And you should always, due to HIPPA, HIPPAs privacy violations,
you want to form the folds so that the confidential information is inside before you
put it in the pocket, okay?
Transcribed by Anam Khalid Monday, July 7
th
, 2014

12

[24] [Punch Biopsy]
[Dr. Shah] So. With that being said, I want to go over punch biopsy procedure. But
before that, are there other questions? Okay, so let me go over the punch biopsy
technique. So the punch is an actual instrument. Okay? It looks like a little cookie
cutter, a round cookie cutter, to tell you the truth. And they have different colored
handles. Okay? They are available in different diameters, two to five millimeters.
Actually, there are bigger punches too. Some of them can be as big as 10 millimeters.
And dermatologists tend to really like to use these and get these in different sizes.
For oral biopsies we usually use the 4 or 5 millimeter punch. The 4 millimeter punch
is good for most oral biopsies and were talking about the size of sample here when
we say 4 millimeters. Okay, so a punch biopsy can be incisional or excisional,
depending on the size of the lesion and the size of the punch, right? So for example,
if your lesion is 3 millimeters and youre using a 4 millimeter punch, then what kind
of a biopsy is that going to be? Excisional. If your lesion is 10 millimeters and youre
using a 5 millimeter punch, then what kind of biopsy would that be? Incisional. So
you see, it depends on the size of the lesion and the size of the punch so I cant tell
you whether the punch is incisional or excisional, okay?

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

[23] [N/A]
[Dr. Shah] Alright. This is the procedure. Basically you have somebody retracting
the area that youre going to do the biopsy in. Youre going to put this thing you
sort of sink this thing in. You have to be very stable and you basically have to make
several circles with the punch biopsy to get a nice round circle, okay? And this is
tricky, I have to say that punch biopsy looks easy but it can be its hard until
youve done a few because of controlling depth. Thats the biggest issue. Theres no
marks on this thing. Theres nothing to tell you how deep youre going. You know,
you could go all the way up to this plastic handle. I mean, theres nothing to control
the depth of this, okay? So you could be too shallow or you could be you know, dig
a deep hole and be too deep. So, it really comes with practice and thats the trickiest
part about the punch biopsy but once youve mastered that, this is a great, great,
great technique. Okay and Ill tell you what the advantages of this area. But, here you
are, okay. Theres alleged lesion under this, maybe its part of a leukoplakia, I dont
know. Okay, and then the punch is here, its going to make a nice, round, 4 or 5
millimeter circle. And the person thats doing this is going to slightly turn this a few
circles so you get a nice, round circle. And it is so important that the person who is
holding the tissue does a good job and that youre stable. Because otherwise you can
go too deep or your punch can go this way and now instead of a circle, youre
making some oval or some other bizarre shape as you go across the tongue. So its
very important that, you know, you stay in one spot when youre doing the punch
Transcribed by Anam Khalid Monday, July 7
th
, 2014

13
biopsy. And again, depth is something that really takes practice. Most of the time,
you just want to make sure you go through the epithelium and into the connective
tissue so we try to get about 3 or 4 millimeters of depth. Okay?

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

[25] [N/A]
[Dr. Shah] So then, this is what you do. You pick up the tissue with, you know, soft
tissue forceps and then you undermine and cut the tissue. This is obviously a
surgical scissor. I would prefer to actually use a scalpel. So you pick up one edge and
you undermine it. And theres a little bit of surgical technique involved in that when
youre removing this tissue you dont want to go too shallow. Theres a tendency
that you start going more and more shallow and, you know, your punch went
deeper. And you want to get as much tissue as you can, so, thats an important thing
here too. Okay? So you can see were removing that.

[26] [N/A]
[Dr. Shah] And then this is whats left behind here. You just have this this is
stating to clot. The tissue was removed from this area, okay? No, theres no suture
in here. This is just the glare. I see what youre referring to. Thats just a glare due to
the photography. Okay.

[27] [Punch Biopsy: Advantages]
[Dr. Shah] Okay, so, any questions about the punch biopsy technique? Im just
going to go over the advantages and the disadvantages and I should be done in the
next five minutes. Does anyone have any questions about the punch biopsy
technique? Once you see it, its an interesting thing to see but the truth is, its going
to look so easy. Youre going to say oh my god, thats so easy. But the issue is, when
you actually do it, controlling the depth and keeping position. It can be an issue. But
once youve mastered that, it is great. So let me tell you why it is great. What are the
advantages of punch biopsy? Well, once youve mastered the depth component, its a
very easy technique, okay? Sutures are not required because when you use a punch
biopsy you have a round hole. You cant really suture that without causing a
Transcribed by Anam Khalid Monday, July 7
th
, 2014

14
contraction scar and ripping tissue. Okay? So, its fast. Its a very fast technique. You
actually get very good healing. Keep in mind when youre using a punch, youre
getting a clean, round hole. And the cleaner your margins, the less the bleeding and
the better the healing. Okay? So thats one of the prime advantages of punch biopsy.
Ill tell you that many times when I do a punch biopsy and I have the patient come
back in two weeks, I dont even know where the biopsy was. I dont even know
where it was done because the tissue heals so well. Okay? And Id like to think its
my expert biopsy technique as well but thats a different story. Faster, better
healing. More useful for lesions located on fixed, non-moveable tissue, okay? So you
really want to make sure its best if you use it on tissue that doesnt move around
because think about it. Because if the tissue is moving around, then you cant control
depth and position as easily. Okay? So, its more useful on fixed tissue on the gingiva,
like the hard palate. However, if you have good retraction, you can use it on any kind
of tissue, okay?

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

[28] [More Punch Biopsies]
[Dr. Shah] Heres some more examples. Theres an example thats being done again
on the bottom of the tongue. And this is the actual tissue thats bleeding with the
round hole around it. Thats going to be removed. Its kind of a rough leukoplakia
here. Okay? Heres another example of a punch biopsy being done. Okay? Any
questions on the punch biopsy? Yeah?

[Student]Since its hard to control depth, why dont they put marks?

[Dr. Shah]I dont know, good question. Maybe we can develop that together. And
go on shark tank or something, I dont know. Yea, I need to come up with an
invention so I can be rich. Okay.

[30] [NYUCD Biopsies]
[Dr. Shah] One thing about me that you may not know, this is probably TMI but
youre not going to believe this one, but Im a poker player. I play, you know, Texas
Hold Em poker and I go to poker tournaments and my dream is to retire and join
the World Series Poker tour so I need an invention. Lets do that so I can go and play.
Okay, last slide, guys. See? You didnt see that one coming, right? The nerdy
pathologist that plays Texas Hold Em poker, right? But Im able to fool a lot of
people, you see? I have a great poker face. Okay. Last slide guys last slide. Give me
your attention for one more minute. Okay. NYUCD biopsies this is just I want
you guys to know that we have an oral pathology lab thats fully licensed and state
certified on the 8
th
floor here, room 844. And this is where I spend a lot of my time
and Dr. Phelan whos going to be lecturing on Thursday spends time and we actually
Transcribed by Anam Khalid Monday, July 7
th
, 2014

15
look at slides under the microscope there. So if you ever do a biopsy or youre an
assistant or youre part of biopsy, which you will be in oral surgery, or something
like that, the specimen goes to the 8
th
floor, room 844. Theres a drop box on the
door for after hours. The specimen, when youre carrying it in the school should
always be in a plastic biohazard bag. Plastic biohazard bag. And then what happens
after we sign for cases in the school, the report is sent to the clinic, GPD and put in
the patients chart. Okay? And that is it. Alright, guys. Thursday, Dr. Phelan will be
here to lecture about salivary gland diseases. See you next Monday.