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NEW YORK –The work of the dermatologist doesn’t need to stop at the lips, according to Nasim Fazel, MD, DDS, a board-certified dermatologist and dentist. she said, speaking at a session focused on oral health and procedures at the American Academy of Dermatology summer meeting.
Whether to perform an incisional or excisional biopsy on the lips or within the oral cavity is a decision driven by the clinical scenario, said Dr. Fazel, professor of clinical dermatology and director of the oral mucosal disease clinic at the University of California, Davis. Variables to consider, she said, include the size of the lesion, as well as whether the lesion is symptomatic or there’s any functional impairment. Other factors to bear in mind are whether the patient has any comorbid inflammatory conditions and whether the lesion could be malignant.
An excisional biopsy is a good procedure for small lesions that are thought to be benign, especially if they are exophytic, she noted. An example would be a traumatic fibroma, she said. This technique is also appropriate if there’s concern for dysplasia or malignancy if an office excisional biopsy is feasible given lesion size and location.
On the labial mucosa, an elliptical incision is often a good choice.
Cutaneous lip procedures
On the cutaneous lip, a punch incision can be feasible. The vermilion border should be marked to maintain orientation. “Avoid transecting the vermilion border to the extent that it’s possible,” said Dr. Fazel. Keep the vascular anatomy in mind as well, she added, since there’s a risk of severing the superior or inferior labial artery with procedures in this area. If this should happen, the branch can be identified and ligated with 4-0 fast gut or chromic gut suture material, she advised.
Another option on the cutaneous lip is shave removal. Here, a chalazion clamp can be used for both exposure and hemostasis. “Always suture parallel to the lip lines, and caution the patient that there may be significant, noticeable blanching when lip anesthesia’s used,” she said.
Gingival and tongue procedures
Moving to territory that may be less familiar for some dermatologists, Dr. Fazel walked through the process of a gingival punch biopsy. “Use local anesthetic, but a small quantity is sufficient,” she said. Using gentle pressure, the operator can work the punch instrument down to periosteal bone. At that point, just scissors can be used for undermining the specimen, with minimal disturbance of the mucosal surface.
Hemostasis after a gingival punch can be accomplished with silver nitrate or aluminum chloride or by electrocautery. A permanent defect in the gingiva can occur even with good technique, she said – a fact that should be included in the informed consent document for the procedure.
For lesions on the tongue, a shave removal can be considered, as can an incisional punch biopsy. An assistant’s hands are invaluable for stabilizing the tongue, said Dr. Fazel, illustrating that small dry gauze squares help achieve a good grip.
Considerations in biopsy technique
Dr. Fazel offered some tips and considerations when a punch biopsy is being done in the context of a chronic oral inflammatory condition, and the plan is to submit for hematoxylin and eosin (H&E) staining and direct immunofluorescence (DIF). Conditions where an intraoral punch biopsy would be considered include bullous or mucous membrane pemphigoid, pemphigus, lichen planus, and systemic lupus erythematosus, she said.
“Select a site with the most significant inflammatory changes” and aim for the most anterior site that exhibits these characteristics to maximize exposure and ensure a good specimen. The labial mucosa is a better choice in general than buccal mucosa, she said. “Maxillary and mandibular sulci are tricky sites,” especially when perilesional and lesional tissue should be included in the biopsies.
Next, Dr. Fazel walked attendees through general principles of preparing for and performing punch biopsies for H&E and DIF. In planning the biopsies, the DIF specimen should ideally be collected before the H&E specimen because the former technique will have higher yield when the specimen is taken from a less bloody field. “The yield of DIF is higher from the gingiva than from nonkeratinized surfaces.”
When infiltrating the biopsy site with local anesthesia, the needle should be centered within the lesion or general area to be biopsied, and care should be taken to maintain the orientation of the lesion to the surrounding tissue. Anesthesia can be infiltrated within the submucosal plane; the resultant ballooning will elevate the tissue to be biopsied and ease the procedure, she said.
Choose a 3-mm punch tool for gingival biopsies; 4 mm is a good size for other nonkeratinized surfaces. Unlike the procedure used for cutaneous biopsies, on delicate oral tissues, “you don’t need to hub your punch tool,” Dr. Fazel said. Similarly, the tool can be driven with firm rotation in one direction, rather than ratcheting back and forth, which may fray and deform the biopsy margins, she added. The specimen can be freed from surrounding mucosa with scissors alone and a gentle snipping motion; everting the tissue will help achieve the desired clean and gentle technique.
Because of the delicacy of the tissue, “it’s important to minimize the use of forceps, as well as any unnecessary manipulation of tissue in the process of specimen collection,” she said.
Salivary gland biopsies and intraoral suturing
Even minor salivary glands can be biopsied in a fairly straightforward way, though there’s a risk of short- and long-term loss of sensation, as well as more scarring than in other routine intraoral biopsies. Though these salivary glands lie just beneath the oral mucosa, care must be taken to avoid laceration of the orbicularis oris muscle during excision, noted Dr. Fazel. With a minor salivary gland biopsy, as with some other intraoral procedures, sutures will be needed. Consideration for the friability of the oral mucosa should drive suture material choice and closure technique.
First, “take bigger bites on each side of the incision, to minimize the risk of the suture tearing through the mucosa,” she said. Avoid forceps while suturing if possible, but be gentle if they are employed, “and be gentle tying knots: retract the mucosa as little as possible and cinch the knots down tightly with your fingers.”
Electrocautery, silver nitrate, and aluminum chloride are all reasonable options for hemostasis, although patients should be alerted that the tissue will have a charred appearance if electrocautery is used. Primary closure may be all that’s needed for hemostasis, said Dr. Fazel.
If nonabsorbable suture materials are used, nylon and prolene should be avoided since they tend to tear through the oral mucosa. Soft or braided silk are good choices, she said, and sutures can come out in 5-7 days.
Absorbable sutures have the advantage of not requiring removal, but they can be more irritating to the surrounding mucosa. Chromic or fast gut are the choices here, said Dr. Fazel. Whether absorbable or nonabsorbable sutures are placed, the size should be 4-0 or 5-0, she said.
Postoperative care, complications, and the limits of the dermatologist
Postoperatively, patients should know that swelling is to be expected, especially with procedures like minor salivary gland biopsies that involve the lip. Icing 15 minutes per hour for the first few hours will help with swelling; wound care is optimized with gentle salt water rinses. A bland diet that avoids acidic, spicy, and excessively hot foods and beverages will minimize wound irritation. Foods with sharp edges like chips, crackers, and nuts can actually catch sutures and cause pain and bleeding, so these too should be avoided.
As with dental work, care should be taken with eating or drinking until anesthesia has worn off, which may take up to 3 hours. Patients should also be cautioned that sutures are likely to come out prematurely just because of the mobility of the structures of the mouth with normal activities such as eating and talking.
Should a wound infection occur, said Dr. Fazel, it’s likely that mixed aerobic and anaerobic bacteria are to blame; accordingly, broad-spectrum beta-lactam antibiotics can be a good first-line course. More severe infections are more likely to have an anaerobic or gram-negative etiology; metronidazole is a reasonable choice for anaerobic coverage, she noted. The life-threatening complication not to miss is cellulitis of the floor of the mouth, or Ludwig angina. The swelling results in superior and posterior displacement of the tongue, obstructing the upper airway, so any patient suspected of having Ludwig angina needs emergent evaluation and treatment.
When should a dermatologist consider referral to an otolaryngologist rather than diving into a biopsy in the dermatology clinic? If the area of concern is on the posterior third of the tongue, access without special tools or higher levels of anesthesia becomes tricky, Dr. Fazel pointed out. The posterior hard palate, the soft palate, and the floor of the mouth are also regions best left to otolaryngologists, she said.
NEW YORK –The work of the dermatologist doesn’t need to stop at the lips, according to Nasim Fazel, MD, DDS, a board-certified dermatologist and dentist. she said, speaking at a session focused on oral health and procedures at the American Academy of Dermatology summer meeting.
Whether to perform an incisional or excisional biopsy on the lips or within the oral cavity is a decision driven by the clinical scenario, said Dr. Fazel, professor of clinical dermatology and director of the oral mucosal disease clinic at the University of California, Davis. Variables to consider, she said, include the size of the lesion, as well as whether the lesion is symptomatic or there’s any functional impairment. Other factors to bear in mind are whether the patient has any comorbid inflammatory conditions and whether the lesion could be malignant.
An excisional biopsy is a good procedure for small lesions that are thought to be benign, especially if they are exophytic, she noted. An example would be a traumatic fibroma, she said. This technique is also appropriate if there’s concern for dysplasia or malignancy if an office excisional biopsy is feasible given lesion size and location.
On the labial mucosa, an elliptical incision is often a good choice.
Cutaneous lip procedures
On the cutaneous lip, a punch incision can be feasible. The vermilion border should be marked to maintain orientation. “Avoid transecting the vermilion border to the extent that it’s possible,” said Dr. Fazel. Keep the vascular anatomy in mind as well, she added, since there’s a risk of severing the superior or inferior labial artery with procedures in this area. If this should happen, the branch can be identified and ligated with 4-0 fast gut or chromic gut suture material, she advised.
Another option on the cutaneous lip is shave removal. Here, a chalazion clamp can be used for both exposure and hemostasis. “Always suture parallel to the lip lines, and caution the patient that there may be significant, noticeable blanching when lip anesthesia’s used,” she said.
Gingival and tongue procedures
Moving to territory that may be less familiar for some dermatologists, Dr. Fazel walked through the process of a gingival punch biopsy. “Use local anesthetic, but a small quantity is sufficient,” she said. Using gentle pressure, the operator can work the punch instrument down to periosteal bone. At that point, just scissors can be used for undermining the specimen, with minimal disturbance of the mucosal surface.
Hemostasis after a gingival punch can be accomplished with silver nitrate or aluminum chloride or by electrocautery. A permanent defect in the gingiva can occur even with good technique, she said – a fact that should be included in the informed consent document for the procedure.
For lesions on the tongue, a shave removal can be considered, as can an incisional punch biopsy. An assistant’s hands are invaluable for stabilizing the tongue, said Dr. Fazel, illustrating that small dry gauze squares help achieve a good grip.
Considerations in biopsy technique
Dr. Fazel offered some tips and considerations when a punch biopsy is being done in the context of a chronic oral inflammatory condition, and the plan is to submit for hematoxylin and eosin (H&E) staining and direct immunofluorescence (DIF). Conditions where an intraoral punch biopsy would be considered include bullous or mucous membrane pemphigoid, pemphigus, lichen planus, and systemic lupus erythematosus, she said.
“Select a site with the most significant inflammatory changes” and aim for the most anterior site that exhibits these characteristics to maximize exposure and ensure a good specimen. The labial mucosa is a better choice in general than buccal mucosa, she said. “Maxillary and mandibular sulci are tricky sites,” especially when perilesional and lesional tissue should be included in the biopsies.
Next, Dr. Fazel walked attendees through general principles of preparing for and performing punch biopsies for H&E and DIF. In planning the biopsies, the DIF specimen should ideally be collected before the H&E specimen because the former technique will have higher yield when the specimen is taken from a less bloody field. “The yield of DIF is higher from the gingiva than from nonkeratinized surfaces.”
When infiltrating the biopsy site with local anesthesia, the needle should be centered within the lesion or general area to be biopsied, and care should be taken to maintain the orientation of the lesion to the surrounding tissue. Anesthesia can be infiltrated within the submucosal plane; the resultant ballooning will elevate the tissue to be biopsied and ease the procedure, she said.
Choose a 3-mm punch tool for gingival biopsies; 4 mm is a good size for other nonkeratinized surfaces. Unlike the procedure used for cutaneous biopsies, on delicate oral tissues, “you don’t need to hub your punch tool,” Dr. Fazel said. Similarly, the tool can be driven with firm rotation in one direction, rather than ratcheting back and forth, which may fray and deform the biopsy margins, she added. The specimen can be freed from surrounding mucosa with scissors alone and a gentle snipping motion; everting the tissue will help achieve the desired clean and gentle technique.
Because of the delicacy of the tissue, “it’s important to minimize the use of forceps, as well as any unnecessary manipulation of tissue in the process of specimen collection,” she said.
Salivary gland biopsies and intraoral suturing
Even minor salivary glands can be biopsied in a fairly straightforward way, though there’s a risk of short- and long-term loss of sensation, as well as more scarring than in other routine intraoral biopsies. Though these salivary glands lie just beneath the oral mucosa, care must be taken to avoid laceration of the orbicularis oris muscle during excision, noted Dr. Fazel. With a minor salivary gland biopsy, as with some other intraoral procedures, sutures will be needed. Consideration for the friability of the oral mucosa should drive suture material choice and closure technique.
First, “take bigger bites on each side of the incision, to minimize the risk of the suture tearing through the mucosa,” she said. Avoid forceps while suturing if possible, but be gentle if they are employed, “and be gentle tying knots: retract the mucosa as little as possible and cinch the knots down tightly with your fingers.”
Electrocautery, silver nitrate, and aluminum chloride are all reasonable options for hemostasis, although patients should be alerted that the tissue will have a charred appearance if electrocautery is used. Primary closure may be all that’s needed for hemostasis, said Dr. Fazel.
If nonabsorbable suture materials are used, nylon and prolene should be avoided since they tend to tear through the oral mucosa. Soft or braided silk are good choices, she said, and sutures can come out in 5-7 days.
Absorbable sutures have the advantage of not requiring removal, but they can be more irritating to the surrounding mucosa. Chromic or fast gut are the choices here, said Dr. Fazel. Whether absorbable or nonabsorbable sutures are placed, the size should be 4-0 or 5-0, she said.
Postoperative care, complications, and the limits of the dermatologist
Postoperatively, patients should know that swelling is to be expected, especially with procedures like minor salivary gland biopsies that involve the lip. Icing 15 minutes per hour for the first few hours will help with swelling; wound care is optimized with gentle salt water rinses. A bland diet that avoids acidic, spicy, and excessively hot foods and beverages will minimize wound irritation. Foods with sharp edges like chips, crackers, and nuts can actually catch sutures and cause pain and bleeding, so these too should be avoided.
As with dental work, care should be taken with eating or drinking until anesthesia has worn off, which may take up to 3 hours. Patients should also be cautioned that sutures are likely to come out prematurely just because of the mobility of the structures of the mouth with normal activities such as eating and talking.
Should a wound infection occur, said Dr. Fazel, it’s likely that mixed aerobic and anaerobic bacteria are to blame; accordingly, broad-spectrum beta-lactam antibiotics can be a good first-line course. More severe infections are more likely to have an anaerobic or gram-negative etiology; metronidazole is a reasonable choice for anaerobic coverage, she noted. The life-threatening complication not to miss is cellulitis of the floor of the mouth, or Ludwig angina. The swelling results in superior and posterior displacement of the tongue, obstructing the upper airway, so any patient suspected of having Ludwig angina needs emergent evaluation and treatment.
When should a dermatologist consider referral to an otolaryngologist rather than diving into a biopsy in the dermatology clinic? If the area of concern is on the posterior third of the tongue, access without special tools or higher levels of anesthesia becomes tricky, Dr. Fazel pointed out. The posterior hard palate, the soft palate, and the floor of the mouth are also regions best left to otolaryngologists, she said.
NEW YORK –The work of the dermatologist doesn’t need to stop at the lips, according to Nasim Fazel, MD, DDS, a board-certified dermatologist and dentist. she said, speaking at a session focused on oral health and procedures at the American Academy of Dermatology summer meeting.
Whether to perform an incisional or excisional biopsy on the lips or within the oral cavity is a decision driven by the clinical scenario, said Dr. Fazel, professor of clinical dermatology and director of the oral mucosal disease clinic at the University of California, Davis. Variables to consider, she said, include the size of the lesion, as well as whether the lesion is symptomatic or there’s any functional impairment. Other factors to bear in mind are whether the patient has any comorbid inflammatory conditions and whether the lesion could be malignant.
An excisional biopsy is a good procedure for small lesions that are thought to be benign, especially if they are exophytic, she noted. An example would be a traumatic fibroma, she said. This technique is also appropriate if there’s concern for dysplasia or malignancy if an office excisional biopsy is feasible given lesion size and location.
On the labial mucosa, an elliptical incision is often a good choice.
Cutaneous lip procedures
On the cutaneous lip, a punch incision can be feasible. The vermilion border should be marked to maintain orientation. “Avoid transecting the vermilion border to the extent that it’s possible,” said Dr. Fazel. Keep the vascular anatomy in mind as well, she added, since there’s a risk of severing the superior or inferior labial artery with procedures in this area. If this should happen, the branch can be identified and ligated with 4-0 fast gut or chromic gut suture material, she advised.
Another option on the cutaneous lip is shave removal. Here, a chalazion clamp can be used for both exposure and hemostasis. “Always suture parallel to the lip lines, and caution the patient that there may be significant, noticeable blanching when lip anesthesia’s used,” she said.
Gingival and tongue procedures
Moving to territory that may be less familiar for some dermatologists, Dr. Fazel walked through the process of a gingival punch biopsy. “Use local anesthetic, but a small quantity is sufficient,” she said. Using gentle pressure, the operator can work the punch instrument down to periosteal bone. At that point, just scissors can be used for undermining the specimen, with minimal disturbance of the mucosal surface.
Hemostasis after a gingival punch can be accomplished with silver nitrate or aluminum chloride or by electrocautery. A permanent defect in the gingiva can occur even with good technique, she said – a fact that should be included in the informed consent document for the procedure.
For lesions on the tongue, a shave removal can be considered, as can an incisional punch biopsy. An assistant’s hands are invaluable for stabilizing the tongue, said Dr. Fazel, illustrating that small dry gauze squares help achieve a good grip.
Considerations in biopsy technique
Dr. Fazel offered some tips and considerations when a punch biopsy is being done in the context of a chronic oral inflammatory condition, and the plan is to submit for hematoxylin and eosin (H&E) staining and direct immunofluorescence (DIF). Conditions where an intraoral punch biopsy would be considered include bullous or mucous membrane pemphigoid, pemphigus, lichen planus, and systemic lupus erythematosus, she said.
“Select a site with the most significant inflammatory changes” and aim for the most anterior site that exhibits these characteristics to maximize exposure and ensure a good specimen. The labial mucosa is a better choice in general than buccal mucosa, she said. “Maxillary and mandibular sulci are tricky sites,” especially when perilesional and lesional tissue should be included in the biopsies.
Next, Dr. Fazel walked attendees through general principles of preparing for and performing punch biopsies for H&E and DIF. In planning the biopsies, the DIF specimen should ideally be collected before the H&E specimen because the former technique will have higher yield when the specimen is taken from a less bloody field. “The yield of DIF is higher from the gingiva than from nonkeratinized surfaces.”
When infiltrating the biopsy site with local anesthesia, the needle should be centered within the lesion or general area to be biopsied, and care should be taken to maintain the orientation of the lesion to the surrounding tissue. Anesthesia can be infiltrated within the submucosal plane; the resultant ballooning will elevate the tissue to be biopsied and ease the procedure, she said.
Choose a 3-mm punch tool for gingival biopsies; 4 mm is a good size for other nonkeratinized surfaces. Unlike the procedure used for cutaneous biopsies, on delicate oral tissues, “you don’t need to hub your punch tool,” Dr. Fazel said. Similarly, the tool can be driven with firm rotation in one direction, rather than ratcheting back and forth, which may fray and deform the biopsy margins, she added. The specimen can be freed from surrounding mucosa with scissors alone and a gentle snipping motion; everting the tissue will help achieve the desired clean and gentle technique.
Because of the delicacy of the tissue, “it’s important to minimize the use of forceps, as well as any unnecessary manipulation of tissue in the process of specimen collection,” she said.
Salivary gland biopsies and intraoral suturing
Even minor salivary glands can be biopsied in a fairly straightforward way, though there’s a risk of short- and long-term loss of sensation, as well as more scarring than in other routine intraoral biopsies. Though these salivary glands lie just beneath the oral mucosa, care must be taken to avoid laceration of the orbicularis oris muscle during excision, noted Dr. Fazel. With a minor salivary gland biopsy, as with some other intraoral procedures, sutures will be needed. Consideration for the friability of the oral mucosa should drive suture material choice and closure technique.
First, “take bigger bites on each side of the incision, to minimize the risk of the suture tearing through the mucosa,” she said. Avoid forceps while suturing if possible, but be gentle if they are employed, “and be gentle tying knots: retract the mucosa as little as possible and cinch the knots down tightly with your fingers.”
Electrocautery, silver nitrate, and aluminum chloride are all reasonable options for hemostasis, although patients should be alerted that the tissue will have a charred appearance if electrocautery is used. Primary closure may be all that’s needed for hemostasis, said Dr. Fazel.
If nonabsorbable suture materials are used, nylon and prolene should be avoided since they tend to tear through the oral mucosa. Soft or braided silk are good choices, she said, and sutures can come out in 5-7 days.
Absorbable sutures have the advantage of not requiring removal, but they can be more irritating to the surrounding mucosa. Chromic or fast gut are the choices here, said Dr. Fazel. Whether absorbable or nonabsorbable sutures are placed, the size should be 4-0 or 5-0, she said.
Postoperative care, complications, and the limits of the dermatologist
Postoperatively, patients should know that swelling is to be expected, especially with procedures like minor salivary gland biopsies that involve the lip. Icing 15 minutes per hour for the first few hours will help with swelling; wound care is optimized with gentle salt water rinses. A bland diet that avoids acidic, spicy, and excessively hot foods and beverages will minimize wound irritation. Foods with sharp edges like chips, crackers, and nuts can actually catch sutures and cause pain and bleeding, so these too should be avoided.
As with dental work, care should be taken with eating or drinking until anesthesia has worn off, which may take up to 3 hours. Patients should also be cautioned that sutures are likely to come out prematurely just because of the mobility of the structures of the mouth with normal activities such as eating and talking.
Should a wound infection occur, said Dr. Fazel, it’s likely that mixed aerobic and anaerobic bacteria are to blame; accordingly, broad-spectrum beta-lactam antibiotics can be a good first-line course. More severe infections are more likely to have an anaerobic or gram-negative etiology; metronidazole is a reasonable choice for anaerobic coverage, she noted. The life-threatening complication not to miss is cellulitis of the floor of the mouth, or Ludwig angina. The swelling results in superior and posterior displacement of the tongue, obstructing the upper airway, so any patient suspected of having Ludwig angina needs emergent evaluation and treatment.
When should a dermatologist consider referral to an otolaryngologist rather than diving into a biopsy in the dermatology clinic? If the area of concern is on the posterior third of the tongue, access without special tools or higher levels of anesthesia becomes tricky, Dr. Fazel pointed out. The posterior hard palate, the soft palate, and the floor of the mouth are also regions best left to otolaryngologists, she said.
EXPERT ANALYSIS SUMMER AAD 2019