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ATTITUDE TOWARDS ORAL BIOPSY AMONG GENERAL

Original Articles
DENTAL PRACTITIONERS OF VADODARA,
A CITY IN THE WESTERN STATE OF INDIA
Rashmi GS Phulari1a* , Mili D Takvani2b , Dharmesh Vasavada1c , Prachi Agrawal1d
1
Department of Oral and Maxillofacial Pathology and Microbiology, Manubhai Patel Dental College and Hospital, Maharaja Krishnakumarsinhji Bhavnagar
University, Vadodara, Gujarat, India
2
Takvani Children and Dental Hospital, Jamnagar, Gujarat, India
aMDS, Professor and Head; e-mail: [email protected]; ORCIDiD: https://orcid.org/0000-0002-5023-2921
bMDS, Consultant Dental Surgeon; e-mail: [email protected]; ORCIDiD: https://orcid.org/ 0000-0002-3202-4643
cMDS, Reader; e-mail: [email protected]; ORCIDiD: https://orcid.org/0000-0003-2075-1920
dBDS, Postgraduate Student; e-mail: [email protected]; ORCIDiD: https://orcid.org/ 0000-0001-5581-0316

ABSTRACT https://doi.org/10.25241/stomaeduj.2022.9(1).art.1

Introduction In practice, the diagnosis of certain oral lesions must be made by biopsy. A biopsy constitutes
an essential diagnostic tool in application to patients with oral pathology. However oral biopsy is not
routinely performed in general dental practice. The present study aimed to explore the attitudes of General
Dental Practitioners (GDPs) towards oral biopsy for diagnosis of oral lesions in Vadodara city, Gujarat, India.
Methodology A questionnaire was distributed to 200 general dental practitioners, consisting of several
items addressing the socio-demographic and professional aspects and their attitudes towards oral biopsy
procedures.
Results Our study showed that 73% of the GDPs do not perform a biopsy on their own. Out of which 32% of
GDPs gave the reason of lack of skills and knowledge while 7% of GDPs lacked confidence in performing a
biopsy on their own. 28% of the GDPs were not aware of the medium of specimen preservation.
Conclusion There is a need for better education and training of GDPs to perform oral biopsy procedures
on their own and create awareness among them about the proper referral of the specimen to oral
histopathological centers which will aid in accurate diagnosis of the lesions.
KEYWORDS
Oral Diagnosis; Attitudes; Biopsy; General Dental Practitioners; Oral Lesions.
1. INTRODUCTION for establishing initial/early diagnosis but also for
providing more accurate clinical surveillance of the
Biopsy is often an indispensable procedure in the disease process.
diagnosis of myriad of benign and malignant oral General dental practitioners (GDPs) often being the
conditions. The term “Biopsy” was introduced into primary oral health care providers are required to
medical terminology in 1879 by Ernest Besnier [1]. have a basic understanding of the biopsy procedure
Biopsy is a procedure consisting of procurement which should be emphasized during undergraduate
of tissue from a living organism with the purpose training and they should be able perform them as
of examining it under the microscope in order to and when required [4]. In general, the GDP is required
establish a diagnosis [2]. The word biopsy originates to detect and recognize oral lesions and inform the
from the Greek terms “bios” (life) and “opsis” (vision): patient accordingly – providing a diagnosis and
vision of life [1,3]. adequate treatment indications. Therefore, GDPs
Biopsy has been one of the oldest methods developed must know not only where, when and how to perform
by the Arab physician Abulcasim (1103-1107AD), a biopsy but also how to manage the information
used for the accurate diagnosis of any abnormality derived from the procedure [6]. Early detection of
in the oral environment as it is an accurate and an oral lesion and prompt biopsy in general dental
pronominal aid used for establishing the histological practice not only reinforces patients’ confidence but
characteristics of lesions which appear suspicious would also reduce the number of successful lawsuits
and so, it helps in their differentiation [4,5]. Biopsy brought for delay or failure to diagnose [4]. Biopsy
of all kinds should be used frequently, not only is advised for all oral lesion in question, if persisting
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Phulari RGS, Takvani MD, Vasavada D, Agrawal P. Attitude towards oral biopsy among general dental practitioners of Vadodara,
a city in Western state of India. Stoma Edu J. 2022;9(1):15-20.
Received: January 31, 2022; Revised: February 11, 2022; Accepted: March 02, 2022; Published: March 04, 2022.
*Corresponding author: Dr. Rashmi GS Phulari, MDS, Professor and Head of Department of Oral and Maxillofacial Pathology and Microbiology
Manubhai Patel Dental College, Vishwajyoti Ashram, Near Vidyakunj School, Munjmahuda, Vadodara 390011, Gujarat, India.
Tel./Fax: +91 9601896824; e-mail: [email protected]
Copyright: © 2022 the Editorial Council for the Stomatology Edu Journal.

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for more than 2 weeks even after the removal of the Among them, 63% (126) of the dentists had been
Original Articles irritating factor, if any. Clinicians have to decide the running their clinics for 1 to 5 years while 18 % (36)
type of biopsy required based on the site, clinical of them had their clinic running for more than 5
nature of the lesion, and proximity to vital structures years. Furthermore, 19% (38) of the dentists had
[7]. been running the clinic for more than 10 years. 175
Many factors may make a biopsy problematic and (87.5%) GDPs had worked at other dental clinics
be reason for not undertaking it in general practice. before opening their own practice. Additionally,
These include: fear of medico-legal implications, 73.5% (147) dentists had consultants of speciality in
unfamiliarity with the biopsy technique, a lack of oral surgery visiting their clinic (Fig. 1).
faith in personal diagnostic skills and the contention
that biopsy is a specialist procedure. There is also
concern that if the lesion proves to be malignant, the
GDP is not equipped to inform the patient that they
have cancer [8]. It is found that many GDPs do not
perform the biopsy procedure on their own in their
routine clinical practice.
Hence the present study aimed to explore the
knowledge and attitudes of general dental
practitioners towards the oral biopsy procedure in
and around the Vadodara city region.

2. METHODOLOGY
Figure 1. Consultant Oral Surgeon at the clinic.
A descriptive, cross-sectional study was conducted
using a questionnaire of 15 questions comprising All the GDPs answered that it was indeed very
2 open-ended and 13 close-ended questions. The important to perform a biopsy. However, only 26.5%
questionnaire was designed to collect information (53) of the GDPs performed a biopsy on their own
about demographics of GDPs, clinical experience while 73.5% (147) of them referred the patient to a
of GDPs, attitudes of GDPs towards oral biopsy, specialist (Fig. 2).
methods used for obtaining biopsy, material used
for specimen preservation, referral to specialized
centers (oral or general pathology laboratories).
The questionnaire was previously evaluated by
means of a cognitive pre-test procedure to ensure
that the questions were appropriate, understandable
among the dental practitioners. The pilot survey
was targeted to five dental professionals selected
due to their accessibility and proximity to the
investigational team. Changes in the questionnaire
were then made accordingly and the pilot study
samples were deleted from the final study sample.
Following which, the purpose of the study was
Figure 2. Performing biopsy on their own.
explained to the GDPs, so consent was obtained and
the questionnaire was given. On answering which type of lesions they encountered
A total of 200 GDPs in and around Vadodara city who during their practice which requires a biopsy, they
consented to participate were included in the study stated that according to their knowledge, cysts
while all professionals exclusively dedicated to some and premalignant lesions were encountered most
dental specialties were excluded. The questionnaire commonly (36% each) while 34% encountered
was distributed and retrieved personally to/from all benign and 32% malignant lesions (Fig. 3).
the dental surgeons who participated in the study
and anonymity in completing the questionnaire was
sought in all cases.
The data collected were tabulated and statistically
analyzed using of descriptive statistics.

3. RESULTS

All of the 200 GDPs who owned their clinics were

approached with the questionnaire, they answered
all the questions considering that their demographic
details would be kept confidential. The response
rate was 100% as the dentists were approached
personally. Figure 3. Lesions encountered requiring biopsy.

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The questionnaire sought to evaluate the knowledge 81% (162) of the GDPs sent the biopsy specimen

Original Articles
of the GDPs regarding the medium of specimen to a private laboratory that they are in contract
preservation after removal. 67.5% practitioners used with, while only 16.5% (33) preferred to send it
formalin as the medium of specimen preservation, to institutions such as government hospitals and
while 20% believed that it can be preserved in saline. dental colleges where more than one pathologist is
Furthermore, 2.5% answered that specimens can be involved in the diagnosis (Fig. 8).
preserved in alcohol; while 5% were not aware of the
medium of preservation of the specimen (Fig. 4).

Figure 8. Analysis of the biopsy specimen is done at.

4. DISCUSSION

Figure 4. Specimen preservation. Biopsy, a Greek-derived word loosely translated

Upon asking what type of biopsy they would perform as “view of the living,” is defined as removal of
53% of GDPs answered incisional biopsy (Fig. 5). tissue from the living organisms for the purpose of
microscopic examination and diagnosis [9].
A biopsy is of paramount importance because it
is strongly related to the early detection of oral
cancer. Although most dentists prefer to refer biopsy
cases to specialist or higher centre, most believe
that routine biopsies are well within the scope of a
GDP as this would provide direct access to prompt
management. GDPs are often unfamiliar with the
different clinical patterns of oral malignancy. In 1955
Boyle commented that an individual’s qualifications
have little to do with their ability to perform a biopsy.
Figure 5. Type of method used. His words appear valid today since the issue of who
should biopsy remains controversial [9,10].
31.4% of the GDPs lacked the experience and skills A wide array of procedures and techniques is
to perform a biopsy. 25.52% of GPDs reasoned that available to assist in the diagnosis of oral disease.
they did not perform a biopsy as they lacked the Every patient should receive a thorough head
materials required for biopsy, while 6.9% opted for and neck examination and appropriate dental
lack of confidence as an answer (Fig. 6). radiographs. The clinical and radiographic exami-
nations may provide sufficient information for
the diagnosis of certain entities. However, many
diseases of the mucosa, other soft tissue and bone
require additional information to make a precise
diagnosis. This information in many instances may
be provided by biopsy and submission of tissue for
histopathologic examination [11].
This study was undertaken to evaluate the
Figure 6. Reasons for not performing a biopsy. knowledge and attitudes of GDPs regarding the
biopsy procedures, medium of specimen preser-
58.5% (117) of the GDPs sent the biopsy to an oral
pathologist for analysis, while 38.5% (77) of them vation, referral to specialist when in doubt and the
sent it to a general pathologist (Fig. 7). choice of referral to a general pathologist or an oral
pathologist, as all these factors do have an impact on
a patient’s diagnosis and treatment plan.
In general dental practice the detection of oral cancer
in an early stage might come across as a difficult task
and to convince patients in order to prevent is also
a continuous challenge in dental field. Therefore,
a dentist must be aware of the factors which play
a very important role in causing cancer, its clinical
signs and symptoms.
Apart from oral potentially malignant disorders
Figure 7. Biopsy specimen sent for analysis. and malignant lesions, there are an array of lesions

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like reactive pathologies (epulis, fibroma), benign competent to perform biopsies while Greenwood
Original Articles epithelial tumors etc. which can be excised in et al. found that only 21% of GDPs were prepared to
toto when detected in a routine dental checkup. carry out biopsies [9,16]. The lack of experience in
Although the patient may not be aware of the performing a biopsy by a GDP is a result of the lack
presence of such lesions, patients can be educated of importance attached to the practical teaching of
about the same and GDPs would be the first to biopsy techniques during their training.
detect and diagnose the lesions at an early-stage, Although the current curriculum of the Dental
building patient compliance towards the GDP. Council of India (DCI) for the Bachelor of Dental
The questionnaire included whether the GDPs Surgery (BDS) degree includes various biopsy
perform the biopsy on their own and they have a techniques in didactic lectures, the clinical quota
consulting oral surgeon coming to their clinic. 73.5% requirement of dental surgery mainly stresses
of GDPs had an oral surgeon coming to the clinic tooth extractions and it does not have any specific
as a consultant while 26.5% of the GDPs perform mention for biopsy procedure [17]. In addition, the
biopsy on their own. This was in accordance with DCI curriculum for the internship of dental students
Warnakulasuriya and Johnson who found that 21% for the undergraduate course emphasizes mainly
of dentists in United Kingdom [12] and Seoane extractions and disimpactions. The requirement for
et al. reported 24.5 % GDP’s perform biopsies in the undergraduate course completion is only one
Northwest Spain [13]. biopsy for an oral cancer case which is not sufficient
Regarding the reasons for not performing a biopsy, as biopsies are to be performed for other lesions as
31.4 % gave the lack of experience and skills as a well. Furthermore, training them at an early stage is
reason, 25.52% went with lack of material, whereas important as the GDPs are the primary or the first
6.9% went with lack of confidence. line of dental care giver. Furthermore, in rural setups
Given the results we can evaluate that in general in countries like India, Oral Surgeons may not be
practice, GDPs encounter a wide variety of benign, always available.
malignant, premalignant, cysts, etc. This allows us to On asking about the type of biopsy they perform,
emphasize the accessibility of GDP to a patient and the majority knew only about incisional biopsy.
his important role in the diagnosis of oral lesions. This explains the need for the GDP to have a
It demonstrates how important it is for a GDP to grasp on biopsy techniques, their indications and
have sufficient knowledge on oral pathology and contraindications. This would assist them to decide
their diagnosis, and also how significant the lack of on the type of biopsy required in individual cases.
knowledge is, as it could lead to misdiagnosis and Regarding the preservation of the specimen after
how it can affect a patient’s treatment. removal and before sending it for analysis, 67.5%
In this study,13.5% of GDPs performed biopsy on GDPs knew that it is supposed to be preserved in
their own which is in accordance with the studies formalin and send to the Oral Pathologist, while 20%
done by Murgod V et al. [4], Cowan et al. [14] and believed that saline could be used for this purpose
Diamanti et al. [11] who reported that 14.93%, 12% Specimen preservation is a very important aspect
and 15% respondents performed biopsies on their in biopsy results. If the tissue is not preserved in the
own respectively. Warnakulasuriya and Johnson proper solution, a lot of artefacts can occur leading
found that 21% of dentists in the United Kingdom to difficulty in diagnosis. This will lead to repeating
[11] and Seoane et al. reported 24.5 % GDP’s perform the biopsy, causing unnecessary trauma to the
biopsies in Northwest Spain [12]. In Norway, Berge patient and a delay in diagnosis thereby, affecting
found that 56% of dentists attempted biopsy [15]. the quality of the treatment given to the patient.
Our study also clearly revealed that 26% of GDPs refer
the patient to a specialist. According to the results 5. CONCLUSION
of the study done by Murgod V et al. in Belgaum
city, in the southern region of India, it was revealed In time we have witnessed that the dental field
that 64.67% of GDPs either call a specialist or refer is growing at huge speed and achieving new
the patient to a higher centre [4]. Reports by Wan developments every day. However, when it comes to
and Savage in Brisbane, showed 76.2% of GDPs refer performing a biopsy which is indeed a gold standard
the biopsy cases to a specialist [1]. The reasons for for the diagnosis of oral cancer, we are inept. Many
not performing a biopsy on their own could be due GDPs do not perform a biopsy on their own due
to several factors like fear of unfamiliarity to biopsy to lack of confidence and skills. There is a need
technique, lack of faith in personal diagnostic skills, for further training in biopsy procedures to gain
lack of materials, misconception that it is a specialist confidence to perform biopsy procedures on their
procedures or concern if the lesion is malignant. own for GDPs in addition to creating awareness with
In our study 31.4% of GDPs gave the lack of skills and accessible pathology support.
knowledge as a reason and 6.9% of GDPs said they We have seen various organisations holding confe-
lack confidence, whereas 46% of them opted for not rences related to many dental procedures but not
giving a specific answer. Wan and Savage stated that many have been organized for basic procedures
58.1% of GDPs did not feel competent to undertake like biopsy. Even during the COVID era, dental
any biopsies mainly due to lack of experience, education has continued unhindered in the form
confidence and practical skills [1]. Diamanti et of online webinars, yet only few sessions were
al. reported 25% of GDP’s surveyed did not feel seen to focus on the biopsy procedures and their

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technical aspects. Oral cancer is definitely difficult course and incorporate the basic biopsy procedure

Original Articles
to deal with, however as the saying goes that as part of the training.
‘Timing is everything’, early and timely diagnosis will
definitely help improve the longevity and quality CONFLICT OF INTEREST
of patients’ lives. Biopsy should be mandatory in all I (we) certify that there is no conflict of interest.
the suspicious lesions and so should be training for
performing biopsy procedures for GDPs. This study AUTHOR CONTRIBUTIONS
was an attempt to urge the concerned organizations RP and MT: concept, protocol, data gathering or analysis and their
to revisit the curriculum of the undergraduate dental interpretation. RP, DV and PA: critically revised the manuscript.

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Rashmi GS PHULARI
DMDS, Professor and Head Department of Oral and Maxillofacial
Pathology and Microbiology Manubhai Patel Dental College Vishwajyoti Ashram
Near Vidyakunj School Munjmahuda, Vadodara, Gujarat, India
CV
Dr. Rashmi G S Phulari, Professor & Head of Department of Oral and Maxillofacial Pathology and Microbiology, Manubhai Patel
Dental College and Hospital, Vadodara, Gujarat. She has authored a textbook titled Textbook of Dental Anatomy Physiology and
Occlusion and a monography titled Age Estimation in Forensic Odontology. She has also published articles in several national
and international indexed journals.

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Questions
Original Articles
1. The term Biopsy was coined by:
qa. Erasmus Wilson;
qb. Ernest Besnier;
qc. Thomas E Bond;
qd. Robert Gorlin.

2. The most common solution for specimen preservation is:

qa. Saline;
qb. Alcohol;
qc. Formalin;
qd. Distilled water.

3. What is the indication for performing a biopsy?

qa. A non-healing long standing lesion;
qb. To arrive at a final diagnosis;
qc. Lesions hampering normal physiological function;
qd. All of the above.

4. Incisional biopsy is
qa. Removal of a small portion of tissue from a larger lesion;
qb Removal of a smaller lesion in toto;
qc. Removal of scrapings from the lesion;
qd. All of the above.

https://www.siprotesi.it/progetti-ed-eventi/primo-congresso-nazionale-sipro/

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