The histological observation of laser biopsy versus scalpel biopsy on plasma cell gingivitis.

Biopsy is one of the histological diagnostic techniques used to assess cells and tissues to determine the presence and extent of a simple nonneoplastic growth to complicated malignancies. In the oral cavity, there are many techniques available to harvest the tissue, it depends on anatomical location and morphology of the lesion. In which many causes artifacts in the specimen due to poor technique and handling, which can lead to diagnostic pitfalls and misery. Laser is one of the advanced surgical tools used to harvest oral tissue with minimal anesthesia and less discomfort. This was a split-mouth case report conducted on smaller lesion (plasma cell gingivitis) to assess laser and scalpel surgical techniques to determine thermal damage of laser biopsy. Copyright:

INTRODUCTION

Oral biopsy is a surgical procedure used to harvest tissue from the oral cavity to determine the histological characteristics of a lesion. In which differentiation, extent or spread of the lesion, and final decision on treatment were determined.[1] Biopsy is a critical diagnostic tool used for suspicious malignancy of enlarged indurated mass, chronic ulceration, and persistent mucosal lesion. Benign and malignant lesions from the oral cavity are originating from the oral mucosa that is covered by stratified squamous epithelium.[2] The biopsy must have clear and readable epithelium and connective tissue to make an unequivocal histological diagnosis. The most widely used and gold standard technique to harvest the tissue was scalpel, because it is easy to harvest and it has accuracy, but it can also cause profuse bleeding that obscures the operative field.[3] In the past two decades, laser was the most commonly used device in dentistry for surgical and nonsurgical procedures, and it was also proved easy to use, efficient, specific, comfortable, and cost-effective,[45] but it also has a disadvantage of thermal and mechanical damages to the biopsy and surgical site.[3]

Plasma cell gingivitis is a rare unique disorder which was first described in late 1960.[6] It is clinically characterized by painful, ulcerated, edematous lesion, and tendency to spontaneous bleeding. Histopathologically, it appears dense and massive plasma cell infiltration into subepithelial connective tissue and it also mimics like life-threatening entities such as squamous cell carcinoma, autoimmune mucocutaneous bullous diseases, and lymphoproliferative disorders. It was also associated with some infectious diseases such as syphilis, Castleman's disease, primary infectious disease of the lymph node, and recently COVID-19.[7]

This was a split-mouth case report conducted on plasma cell gingivitis (smaller lesion) to observe difference in histopathological changes on excisional biopsy using the laser (diode) and scalpel surgical technique on the same patient.

CASE REPORT

A 38 year old female patient reported to the Department of Periodontics, Karpaga Vinayaga Institute of Dental Sciences, chengalpattu, Tamilnadu, India, the chief complaint of the patient was swelling and bleeding in the gums for the past 2 months. The medical history was noncontributory and hemogram reports were normal. On examination, marginal gingiva and interdental papilla on the labial aspect of the maxillary anterior region in relation to tooth numbers 11, 12, and 21 appeared reddish, enlarged and extended into the attached gingiva. The lesion was painless, soft, and bleeds on palpation, and part of treatment oral prophylaxis was done, and the patient was asked to report after 2 weeks for review. On review of the patient, there was no recovery of the lesion and provisionally diagnosed as plasma cell gingivitis. Patient consent form obtained and planned for excisional biopsy with scalpel in tooth number 11, 12 and diode laser in tooth number 21 and patient asked to report after 1 month for review. Scalpel biopsy specimen [Figure 1] showed stratified squamous epithelium with underlying connective tissue densely infiltrated with plasma cells. Laser biopsy specimen [Figure 2] showed loss of epithelium with underlying connective tissue densely infiltrated with plasma cells.

Figure 1

Scalpel biopsy shows stratified squamous epithelium (A); with plasma cells infiltration (B)

Figure 2

Laser biopsy shows loss of epithelium (A); with plasma cells infiltration (B)

Postoperative review on day 30, the lesion was subsided, and histological healing was assessed on both scalpel and laser surgical sites. The postsurgical healing site specimen with scalpel [Figure 3] showed thinned epithelium with fewer blood vessels and with laser [Figure 4] showed thickened epithelium with numerous blood vessels.

Figure 3

Scalpel on day 30 healing site. Thinned epithelium (A); with minimal blood vessels (B)

Figure 4

Laser on day 30 healing site. Thickened epithelium (A); with rich blood vessels (B)

DISCUSSION

Oral biopsy is a critical diagnostic aid when the lesions cannot be diagnosed based on history and clinical examination.[8] It is helpful to establish a definitive diagnosis and prognosis on premalignant or malignant lesions and make sure the lesion has been completely removed.[9] Oral biopsies can be taken in many techniques, whatever the method, the ultimate goal is to give typical sample to the pathologist for interpretation and provide perioperative comfort to patients. In case a defective sample of specimen can make faulty diagnosis leads to treatment failure and recurrence of the lesion.[10]

Traditionally, the scalpel has been considered the gold standard technique because of its precision control and preservation of tissue integrity. Later, laser was proven to be easy to use, efficient, cost-effective, and produce heat during a procedure causes drying, vaporization, and carbonization that leads to protein denaturation and coagulation at the surgical site, this seals the blood vessels and inhibits pain receptors that reduces pain and inflammation, and it also disinfects the surgical site and improves wound healing.[3]

In the present case report, biopsy was compared between laser and scalpel surgical techniques on plasma cell gingivitis of the same patient. For laser surgical technique, Diode Laser was used at wavelength of 810 nm in pulsed mode with 200 μm fiber and output power of 3.5W CW, it causes minimal bleeding with more surgical time, in scalpel surgery, there was profuse bleeding with less surgical time was taken, and the patient was comfortable in both laser and scalpel surgeries. Histopathological results of laser specimen showed loss of epithelium, loss of margin of connective tissue, and the remaining connective tissue infiltrated with plasma cells. In scalpel specimen, epithelium was intact and connective tissue was infiltrated with plasma cells. On postoperative day 30, laser biopsy specimen showed thickened epithelium with numerous blood vessels in connective tissue, and in scalpel specimen showed thinned epithelium with few blood vessels in surgical site, postoperative healing was good with laser.

Yanduri conducted a study on laser versus scalpel biopsy technique in the oral lesion and reported that laser has an advantage of providing hemostasis during surgery compared to scalpel. On the other hand, overheat was produced by the laser can cause damage to the epithelium and connective tissue (fulguration artifact). A specimen with fulguration artifact is associated with epithelial loss, and it also affects the nuclei of cells causes spindled, palisading, and hyperchromatic nuclei. This change can mimic the appearance of epithelial dysplasia and lead to an incorrect histopathological diagnosis, it occurs especially at the margins, which are extremely important for the clinician in terms of the presence/absence of dysplasia and invasion. Finally, he stated that the use of a laser should be limited to excisional biopsies with relatively large sample size where the adequate margin is available and used with low power laser, which was effectively decrease the risk of separating the epithelium from the basement membrane.[1] Bhatsange also reported that laser produces thermal artifacts that may interfere with histologic interpretation of the lesion and it should be used with caution for diagnostic biopsy or when information from the margins is required.[3]

The presence or absence of epithelium in conditions such as epithelial dysplasia and epithelial invasion is extremely important in the histopathological evaluation of premalignant and malignant lesions. One of the major disadvantages of laser in biopsy with respect to the damage occurs at the margins of the lesion.[1] This laser-tissue interaction at the margins may produce some artifactual changes, such as thermal damage and coagulation which may impair the histopathological diagnosis.[2]

CONCLUSION

Biopsy is a vital tool to diagnose oral mucosal lesion, although many techniques exist to harvest biopsy specimen, the ultimate goal is to obtain an ideal tissue sample to facilitate histopathological interpretation. Laser although provide good operative field with wound healing should be cautious on smaller lesion due to marginal damage of the biopsy specimen, because many of the oral lesions originated from oral epithelium.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.