(60) Variability in Incisional Biopsy Techniques Across Specialists

Abstract: The literature is controversial regarding surgical approach and technique for incisional biopsies of oral soft tissue pathology. Current literature begins to outline a standard,¹ but past literature is sparse and conflicting. Because of this, there is variability amongst practitioner techniques including biopsy site selection. Oral and maxillofacial surgery (OMS) resources^2,3 recommend biopsying the border of a lesion including normal tissue. A biopsy from the margin of a malignant or premalignant lesion is unlikely to demonstrate the most representative and severe histopathology. This can lead to misdiagnosis, underdiagnosis and a delay in treatment – ultimately increasing mortality in this patient population.⁴ This initial study will establish a baseline for incisional biopsy site selection amongst OMFSs and compare that with other specialists who perform biopsies including oral and maxillofacial pathologists (OMFP) and oral medicine practitioners (OM).
Stage I of this study (IRB exempt HM20031373) includes a survey sent to OMS, OMFP and OM specialists in academic healthcare centers. The survey (Fig 1) gathers demographic data including training background. Through an interactive interface, the final questions ask the participants to review clinical images of soft tissue oral pathology without a diagnosis and indicate their site selection for incisional biopsy. Logistic regression is used to analyze if participants' clinical experience and training affect their accuracy in selecting biopsy sites. Accurate site selection was defined by a multidisciplinary team including an OMS, OMFP, and OM.
Prior to stage I, a pilot of the survey was deployed to a small study population consisting of board-certified oral and maxillofacial surgeons within an academic health care center. Table 1 and Table 2 exhibit responses for the demographics and clinical experience sections. Experience is varied with notable points. 89% graduated from CODA Accredited 4-year OMS programs. None of the oral and maxillofacial surgeons in this pilot had head and neck oncology fellowship training and only 33% had presented to an interdisciplinary tumor board during their residency. All of the respondents currently perform biopsies (except 1, retired).
Figures 2, 3, 4, 5, 6 display the clinical photos with the respondents’ biopsy site selections compared to the gold standard site. In Figure 2, clinicopathological diagnosis of proliferative verrucous leukoplakia, only 55% of the respondents were accurate. In Figure 3, a primary squamous cell carcinoma, 11% of the respondents were accurate. In Figure 6, a salivary gland tumor, 77% were accurate. Figures 4, 5, mucous membrane pemphigoid, asked the clinician to not only perform site selection, but to do so with considerations for hematoxylin and eosin staining and direct immunofluorescence.
We expect that Stage I (to be presented at AAOMS 2025) will yield similar results to the pilot with a larger study population. We anticipate that specialists with oncologic training will exhibit higher accuracy in biopsy site selection.
Despite the responsibility of the practicing OMFS to address premalignant and malignant pathology, there is controversy in the literature regarding techniques for biopsy. This study aims to identify a correlation between this controversy and inconsistencies in surgical techniques amongst oral and maxillofacial surgeons. In the pilot, 88% of practitioners chose to biopsy the margin of Fig 3, a squamous cell carcinoma, while 11% chose to biopsy the center (most representative site) of the lesion.
This study aims to build awareness in the OMFS community and ultimately establish an accepted standardized approach proposed by a multidisciplinary team of OMS, OMFP, and OM specialists.

American Association of Oral and Maxillofacial Surgeons. (2023). Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners.

Hupp, J. R., Tucker, M. R., & Ellis, E. (2013). Contemporary Oral and Maxillofacial Surgery-E-Book: Contemporary Oral and Maxillofacial Surgery-E-Book. Elsevier health sciences
Figure 1Figure 2-6Table 1 and 2