Biopsy And Healing Of Oral Wounds Short Notes

Biopsy and Healing of Oral Wounds

Question 1. What is biopsy?
Answer. Biopsy is the removal of tissue from the living organism for the purpose of microscopic examination and diagnosis.

Question 2. What is autopsy?
Answer. Autopsy is the removal of tissue from a dead organism for the purpose of microscopic examination and investigation.

Read And Learn More: Oral Pathology Short Notes Question And Answers

Question 3. Name the different types of biopsies.
Answer.

• Surgical biopsy: Incisional biopsy, excisional biopsy and punch biopsy
• Fine needle aspiration cytology (FNAC) and CT-guided FNAC
• Exfoliative cytology
• Brush biopsy
• Frozen section biopsy
• Endoscopic biopsy
• Cone biopsy
• Core-needle biopsy
• Suction-assisted core needle biopsy
• LASER biopsy.

Question 4. What is excisional biopsy?
Answer. If a lesion is totally excised for histological evaluation, it is called excisional biopsy.

Question 5. In which situation excisional biopsy is done?
Answer. This type of biopsy is usually done for microscopic diagnosis of small lesions.

Question 6. What is incisional biopsy?
Answer. When only a small section of tissue is removed from a large lesion for the purpose of histological evaluation, it is called incisional biopsy.

Question 7. In which situation incisional biopsy is done?
Answer. This type of biopsy is done in the cases where the lesion is either too large to excise before knowing the exact nature of the disease or when the lesion is of such a nature that total excision would be irrational.

Question 8. What is punch biopsy?
Answer. Punch biopsy is a type of surgical biopsy, in which tissues are obtained from lesions with the help of a circular blade, which is attached to a pencil-like handle. It is ideal for obtaining tissue from external skin or mucosal surfaces.

Question 8a. How punch biopsy is obtained?
Answer. The circular blade is placed over the surface of the lesion and is rotated down through the epidermis and dermis, and into the subcutaneous fat producing a cylindrical core of tissue.

Question 9. In which cases punch biopsy is indicated?
Answer. It is very useful in obtaining tissue samples from the skin and mucous membrane; is frequently used for removing tissue samples from a variety of lesions e. g. oral and skin cancers and precancers, vesiculo-bulous lesions, moles and small lumps, etc

Question 10. What is cone biopsy?
Answer. It is a surgical biopsy and it removes the tissue which is cylindrical or cone shaped. The advantage of this technique is that it provides a large sample of tissue.

Question 11. What is fie needle aspiration cytology (FNAC)?
Answer. FNAC is done by aspirating tissue materials from deep inside the core of a lesion and this biopsy is done with a fie needle attached to a syringe. During biopsy the needle is inserted into the lesion and then vacuum is created so that tissue samples are sucked into the syringe.

Question 12. Fine needle aspiration cytology (FNAC) is commonly performed in which tissues?
Answer. It is commonly done for obtaining tissues from glandular or cystic lesions.

Question 13.What is CT-guided FNAC?
Answer. CT-guided FNAC technique is same as conventional FNAC, however, as the imaging facility attached with the instrument it helps in properly locating the wound to be biopsied.

Question 14. What is core needle biopsy (core biopsy)?
Answer. The technique is partly same as FNAC but here after the needle (2 mm in diameter) has been inserted into the target lesion, the needle is advanced further within the deeper cell layer to remove the core tissue. The needle has a cutting tip that helps in removing tissue. The advantage of this technique is that it is more defiitive procedure than FNAC and can be used in inaccessible lesions.

Question 15. What is vacuum assisted core biopsy?
Answer. In vacuum assisted core biopsy the biopsy syringe is attached to a suction associated with a vacuum device. Advantage of this technique is that it helps in removing multiple samples in one needle insertion.

Question 15a.What type of biopsy is recommended in lesion measuring 1 to 1.5 cm in diameter?
Answer. Excisional biopsy.

Question 16. What is frozen section biopsy?
Answer. Frozen section biopsy is performed in order to get an immediate histological report of a lesion (e.g. to determine whether a lesion is malignant or not, or to evaluate the margin of an excised cancer to ascertain that the entire lesion is removed at the time of surgery).

Question 17. What is the procedure of frozen section biopsy?
Answer. The tissue is obtained from a lesion and the fresh tissue is quickly frozen at about –70° C in liquid nitrogen or dry ice. The frozen tissue is then sectioned in a refrigerated microtome and then stained to get a prompt diagnosis.

Question 18. What is the limitation of frozen section biopsy?
Answer. In this type of biopsy the slides cannot be preserved for future references; hence photomicrographs of the slides are important.

Question 19. What is brush biopsy?
Answer. This technique is used to collect cells from the surface as well as subsurface layers of suspected lesions for microscopic examination. A round stiff bristle brush is rotated vigorously at a particular site of the lesion until bleeding starts, which ensures a suffiiently deep sample. Smear is prepared from the sample, which is scanned under microscope to detect any abnormal cells.

Question 20. Why decalcifiation is sometimes necessary of the biopsy specimen?
Answer. If the biopsy specimen is a calcifid tissue (e.g. bone and tooth) then decalcifiation of the said specimen is to be done before the standard processing and sectioning.

Question 21. Name the common decalcifying agents used for this purpose?
Answer. Decalcifiation is usually done by keeping the specimen in ethylene diamine tetraacetic acid (EDTA) or acid solutions.

Question 22. Describe the basic steps in biopsy procedure.
Answer.

• The area of the wound from where the biopsy will be done is cleaned fist
• The area should be anesthetized however, the anesthetic solution should not be injected directly into the lesion
• Tissue should be obtained from the most representative site of the wound or sometimes the entire wound is removed in case of a small lesion
• The tissue is obtained in such a way that it should include both the diseased area as well as some normal tissue at the border of the wound
• The biopsy specimen should be of suffiient thickness and depth (size of the sample should be at least 1 × 0.6 cm and the depth should be 2 mm)
• Edge of the specimen should be vertical and not beveled
  After obtaining the tissue, it should be immediately placed on a glazed paper to avoid tissue curling
• After the tissue is obtained, it should be cleaned and then put into 10 percent formalin solution for fiation
• The sample should be labeled properly with patient’s name and the clinical details the lesion
• The biopsy site is sutured after achieving hemostasis
• The biopsy specimen is sent to the histopathologist for diagnosis after labeling it properly.

Question 23.Why fiation of the biopsy specimen is necessary.
Answer. Fixation of the tissue specimen is necessary immediately after biopsy to avoid autolysis; which may cause loss of microscopic details.

Question 24. What is the common fiative used for tissue fiation after biopsy?
Answer. Ten percent formal saline (formaldehyde solution in normal saline or a neutral pH buffer) is the routinely used fiative in biopsy.

Question 25.For proper fiation how long the specimen should in the fiative?
Answer. At least for 24 hours.

Question 26. How labeling of the tissue sample is done while sending it to the histopathologist?
Answer.

• Mention the name, age, and sex of the patient
• Mention the date and time of biopsy
• Mention the type of biopsy, the site from where it is obtained and the nature of the tissue (e.g. bone tissue or soft tissue, etc.)
• Mention the brief clinical, radiological and other relevant features of the lesion (if any)
• Mention the provisional diagnosis.

Question 27. Describe the basic steps in tissue processing after biopsy.
Answer.

• After fiation of the tissue, it is dehydrated in a series of solvents
• It is then impregnated with paraffi wax and a wax block is prepared
• The wax block is mounted on a Microtome and ultrathin sections (4 μm) are made
• The section is mounted on a glass microscope slide for staining.

Question 27a. What is the average thickness of a tissue section in case of histopathological examination?
Answer. About 4 μm.

Question 27b. What is the most common stain used for histopathological examinations?
Answer. Hematoxylin and Eosin stain is the most routinely used for staining of the tissue.

Question 28. In hematoxylin and eosin stain, which part of the dye is basic and which part of it is acidic in nature?
Answer. Hematoxylin is the basic dye, which stains the tissue blue-black, while eosin is the acidic dye which stains the tissue red.

Question 29. Name the tissues or tissue components, which stain with hematoxylin (basic dye) in hematoxylin and eosin staining.
Answer.

• Nucleus (DNA, RNA)
• Ground substance of connective tissue
• Reversal lines of bone.

Question 30. Name the tissues or tissue components, which stain with eosin (acidic dye) in hematoxylin and eosin staining.
Answer.

• Cell cytoplasm
• Keratin
• Muscle cytoplasm
• Decalcifid bone collagen.

Question 31. When should the biopsy procedure be repeated?
Answer.

• If a report or diagnosis comes which is totally unexpected in terms of what was clinically or radiologically presumed earlier
• Biopsy should be repeated in case any difference arising between the pathologist and the surgeon regarding the diagnosis.

Question 32. If standard histopathology fails to give a confimatory diagnosis then what should be done?
Answer. In that case special staining and other investigations should be done, e.g. histochemistry, immunohistochemistry, DNA analysis, tissue culture or animal inoculation, etc.

Question 33. Name the common reasons for biopsy failure.
Answer. Biopsy procedure may fail or a negative report may come due to the following reasons:

• Specimen obtained from unrepresentative site of the lesion
• Damaged or improperly fied specimen
• Tissue specimen of insuffiient depth
• Pre-existing severe inflmmation or secondary infection in the area of biopsy.
• Microscopic features are too diffiult to interpret as in poorly differentiated lesions
• Lesion with non-specifi histological fidings e.g. aphthous ulcer.

Question 34. What is exfoliative cytology?
Answer. Exfoliative cytology is the microscopic study of cells obtained from the surface of an organ or lesion after suitable staining.

Question 35. Based on which biologic principle exfoliative cytology is done?
Answer. The neoplastic cells or cells from many surface lesions are generally less cohesive than the normal cells and usually they shed on the surface of the lesion or into the secretion (e.g. the saliva).

Question 35a. How the cells are obtained in case of exfoliative cytology?
Answer. These exfoliated cells are obtained from the lesion by scrapping its surface and are then microscopically evaluated for possible cellular changes.

Question 35b. Name the common lesions in which exfoliative cytology can be useful.
Answer. Cancer, ulcerated lesion, detection of virally infected cells, acantholytic cells and candidal hyphae, etc.

Question 36. Describe the technique of exfoliative cytology.
Answer.

• First of all the surface of the lesion is cleaned by removing all the debris and mucins, etc.
• After that, gentle scrapping is done on the surface of the lesion with a metal cement spatula or a moistened tongue blade for several times
• Thus materials present on the surface of the lesion are adhered or collected at the border of the instrument
• The collected material is then evenly spread over a microscopic slide and is fied immediately with either 95 percent alcohol or equal parts of alcohol and ether
• The slide is then air-dried and is stained by a special stain called PAP stain (Papanicolaou stain).

Question 36a. Why the PAP stain is named so?
Answer. It is named after George Nicholas Papanicolaou, who introduces this multichromatic stain for using in cytology smears.

Question 37. Name the advantages of exfoliative cytology.
Answer.

• Anesthesia is not required in this technique
• It is most useful for screening of various lesions
• It is a quick, simple, painless and bloodless procedure
• It helps to check the false-negative biopsy cases
• Special procedures like immunohistochemistry can be performed in exfoliative cytology samples
• The procedure is especially helpful in follow-up detection of recurrent cancer cases
• It helps in quick screening of large number of cases, which do not look like cancers clinically.

Question 38. What are the limitations of exfoliative cytology?
Answer.

• It is not a substitute for but an adjunct to the conventional surgical biopsy
• However it is unreliable for confimatory diagnosis of cancers as large numbers of false negative test results are often found.

Question 39. How interpretations are done on the fidings of exfoliative cytology?
Answer. The fidings in exfoliative cytology smears are categorized into fie classes:

• Class I: Presence normal cells
• Class II: Presence of atypical cells
• Class III: Presence of intermediate type cells
• Class IV: Cellular appearance suggestive of cancer
• Class V: Cellular appearance positive of cancer.

Question 39a. What further action to be taken in Class IV type of exfoliative cytology?
Answer. Biopsy which is mandatory.

Question 39b. Is biopsy necessary in class III type of cytology?
Answer. Biopsy should be recommended as the report is of intermediate type (falls between noncancer and cancer).

Question 40. Give the indications of exfoliative cytology.
Answer.

1. Herpes simplex
2. Herpes zoster
3. Pemphigus vulgaris
4. Pemphigoid
5. Squamous cell carcinoma
6. Biopsy and Healing of Oral Wounds 345
7. Aphthous ulcer
8. Candidiasis.

Question 41. Name the factors determining the healing of oral wounds.
Answer.

• Age of the patient
• Type of tissue where healing is taking place
• Location of the wound
• Mobility of the wound
• Trauma
• Local temperature
• Radiation
• Nutritional factors
• Circulatory factors
• Infections
• Hormonal factors.

Question 42. What is the inflence of age on the healing of oral wounds?
Answer. The rate of wound healing in younger individuals is faster in comparison to that of the older individuals and the reason may be due to higher rate of tissue metabolism in the former.

Question 43. Does the rate of healing differ in different tissues?
Answer. Yes, different types of tissue in our body exhibit a great deal of variation in their healing potential. For example, the epithelial tissue heals up at a much faster rate in comparison to the neural tissue.

Question 44. How location or site of the wound inflences the healing process?
Answer. Wounds in an area of good vascular supply should heal more rapidly than those located in the relatively avascular areas.

Question 45. How the tissue mobility at the site of injury affects healing?
Answer. If the wound site is subjected to constant movements, the rate of wound healing is delayed and it may be due to repeated disruptions of the newly formed connective tissue. On the other hand the immobilized soft tissue or bony wounds usually heal at a faster pace.

Question 46. What is the inflence of trauma in tissue healing?
Answer. Mild trauma to the tissue may hasten its healing process, but severe trauma defiitely retards the healing.

Question 46a. Name the vascular changes in acute inflmmation.
Answer. Vasodilatation, increased vascular permeability and stasis of blood.

Question 46b. Distribution of blood flw in any organ is mainly regulated by which structures?
Answer. Arterioles.

Question 47. Does local temperature in the area of wound inflence healing?
Answer. If the local temperature in the area is high and it is well maintained, the healing process occurs at a faster rate. But if the local temperature in the area is low, the healing process can be delayed.

Question 48. How local tissue radiation affects healing of wound?
Answer. Low dose of radiation in the tissue stimulates its healing process; however, a high dose of radiation defiitely disturbs the same.

Question 49. What is the role of nutrition in tissue healing?
Answer. Nutritionally defiient persons (especially with defiiency of vitamin C, proteins and minerals, etc.) usually exhibit a slower rate of wound healing.

Question 50. What is the importance of local tissue circulation in wound healing?
Answer. Tissue with a very good blood supply heals at a faster rate in comparison to the tissue whose blood supply is diminished due to certain reasons, e.g. anemia, tissue dehydration or aging, etc.

Question 51. How local infections affect the tissue healing?
Answer. A low-grade infection in the tissue may stimulate its healing process. A sterile wound on the other hand heals at a slower pace; however, severe infections in the tissue always disturb the healing process.

Question 52. What are the roles of hormones in tissue healing?
Answer. The trephones (wound hormones) released by proteolytic breakdown of cellular debris, accelerate the healing process. Administration of other hormones, e.g. ACTH, cortisone,etc. causes an inhibition in the growth of granulation tissue and thereby results in delayed wound healing.

Question 52a. During healing of an oral ulcer, where from the epithelial cells generate to cover up the wound?
Answer. The epithelial cells generate from the intact epithelium surrounding the wound.

Question 52b. What is tissue hyperplasia?
Answer. Growth of tissue due to increase in the number of cells.

Question 52c. What is tissue hypertrophy?
Answer. Growth of tissue due to increase in the size of cells.

Question 52d. What is tissue atrophy?
Answer. Decrease in size of tissue due to decrease in the size of its constituent cells.

Question 53. What is healing by fist intention (primary healing)?
Answer. When the cut surfaces of a wound can be approximated or closely sutured, the healing which occurs in such wounds are called healing by primary intention.

Question 54. What is healing by secondary intention (secondary healing)?
Answer. When the opposing margins of the wound cannot be approximated together by suturing,the wound fils up from the base with the formation of a larger amount of granulation tissue, such type of healing of the open wound is known as healing by secondary intention or secondary healing.

Question 54a. Tensile strength of a wound undergoing healing depends upon which factor?
Answer. Quantity and quality of collagen fiers formed in the wound.

Question 55. What is dry socket?
Answer. Dry socket or alveolar osteitis can be defied as the failure of appropriate healing after tooth extraction due to disruption of initial clot with eventual lack of organization by granulation tissue.

Question 55a. What is the main reason behind development of dry socket?
Answer. Disintegration of blood clot from the site of tooth extraction.

Question 56. Enumerate the possible causes of development of dry socket.
Answer.

• Traumatic extraction
• Smoking after extraction
• Excessive rinsing after tooth extraction
• Oral contraceptives use during extraction
• Foods being impacted in the socket
• Limited local blood supply
• Excessive use of vasoconstrictors in the local anesthesia
• Osteosclerotic bone disease
• Previous radiotherapy
• Pre-existing pericoronitis.

Question 57. Describe the pathogenesis of dry socket.
Answer. After a tooth is extracted blood clot forms; which stops further bleeding, protects the wound and promotes healing. Dry socket develops if the blood clot is lost from the wound and the bony wall of the socket is exposed to the air, food and flids, etc.

Question 57a. Dry socket more frequently develops after extraction of which tooth?
Answer. Mandibular third molars.

Question 58. Is dry socket a type of osteomyelitis?
Answer. No, it a type of osteitis.

Question 59. Describe the brief clinical features of dry socket.
Answer. In case of dry socket, patients complain of intense, continuous, deep seated and throbbing type of pain with foul breath. Clinically the extraction socket is devoid of blood clot and the bony walls of the socket are bare, whitish and visible. Dead bones from the socket wall may shed as crumb-like fragments.

Question 59a.During healing of an extraction wound, wherefrom the osteoblasts and the epithelial cells are generated to produce new bone and epithelium?
Answer. Osteoblasts are generated from the undifferentiated mesenchymal cells of the periodontal ligament tissue; while the epithelial cells are generated from the intact epithelium at the wound margin.

Question 60. What is replantation of teeth?
Answer. Replantation is defied as purposeful removal of a tooth and its almost immediate implantation back into the same bony socket after performing root canal treatment and retrograde filing outside mouth.

Question 61. Why replantation of tooth is done?
Answer. Replantation is planned to save a tooth where conventional endodontic therapy or endodontic surgery has failed. It is a system of organization, sterility and quickness.

Question 62. Name the conditions in which replantation of tooth is indicated.
Answer.

• Teeth with difficult access to the root canals (e.g. lower 2nd molar)
• Anatomic limitation: tooth apex in close proximity to the important nerves and vessels
• Apical perforations in areas not accessible surgically
• Medically compromised patients: handicapped, geriatric and non–cooperating
• Failed previous apical surgery
• To preserve post-extraction alveolar bone for a prosthesis
• Accidental avulsion of tooth.

Question 63. Name the situations where tooth replantation is not advisable.
Answer.

• Pre-existing moderate to severe periodontitis
• Curved or flred roots
• Non-restorable tooth
• Missing interseptal bone.

Question 63a. What is the principal cause of failure of tooth replantation?
Answer. External resorption of tooth roots.

Question 63b. The key factor in the success of tooth replantation is?
Answer. Preservation of healthy periodontal ligament.

Question 64. What is transplantation of tooth?
Answer. Tooth transplantation refers to the replacement of one damaged natural tooth by another natural tooth of the same person or another person.

Question 65. What is the most common example of tooth transplantation?
Answer. Most common example of transplantation is replacement of mandibular fist molar tooth by a developing mandibular third molar.

Question 66. What is autogenous transplantation?
Answer. Autogenous transplantation is the one where the replacing tooth is obtained from the same person.

Question 67. What is homologous transplantation?
Answer. Homologous transplantation is the one where the replacing tooth is obtained from another person.

Question 67a. Which type of transplantation is generally more successful—autogenous or homologous?
Answer. Autogenous transplantation.

Question 68. Does the transplanted tooth behave clinically and physiologically like a normal viable tooth?
Answer. Yes, once a tooth is transplanted it remains stable in the new location since it develops fresh periodontal ligament, cementum, gingiva, epithelial attachment and alveolar bone,etc.

Question 69. Is the pulp of a transplanted tooth vital?
Answer. Yes, the pulp remains vital in such tooth and it becomes revascularized.

Question 70. Enumerate the criteria of successful tooth transplantation.
Answer.

• The transplanted tooth must have attachment in the new socket like that of a normal tooth with the development of new periodontal ligament, alveolar bone, gingiva and epithelial attachment, etc.
• The tooth should be physiologically, clinically and radiographically normal and vital
• The transplanted tooth must be cosmetically acceptable and should perform masticatory functions as good as any other tooth in the jaw
• There should not be any periodontal or peri-apical lesions or any abnormal root resorptions.

Question 71. Name the causes of failure of transplantation of tooth.
Answer.

• Lack of generation of fresh attachment tissues in the new socket
• Infections
• Resorption of roots.

Question 72. What are osteo-integrated implants?
Answer. Osteo-integrated implants are those in which a direct, functional and structural union develops between the living bone and the surface of the implant.

Question 72a. How many weeks after placement of an implant radiographic evidence of bone generation may be visible around it?
Answer. Approximately 6 to 8 weeks.

Question 73. What is pseudoarthrosis?
Answer. During healing of an old fracture, cartilaginous tissue may develop over the broken ends of bone with a cavity containing clear flid; this phenomenon is called pseudoarthrosis.

Question 74. What is gomphosis?
Answer. The normal attachment or bonding between tooth and the alveolar bone is known as gomphosis.