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 Table of Contents  
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 21-25

Attitudes of general dental practitioners toward biopsy procedures – A survey

Private Practitioner, Tamil Nadu, India

Date of Submission06-Oct-2021
Date of Acceptance24-Oct-2021
Date of Web Publication29-Nov-2021

Correspondence Address:
Dr. S Aishwariya
Private Practitioner, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijosr.ijosr_8_21

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Introduction: Biopsies are one among the diagnostic procedures in the detection of malignancy but are not conventionally performed in dental practice due to the fear of medicolegal complications, unfamiliarity with the technique, and the misconception of it being a predominantly specialist procedure. This survey was therefore aimed to explore the knowledge, attitudes, and practices of general dental practitioners (GDPs) toward biopsy procedures. Materials and Methods: A self-designed questionnaire was administered to 50 dentists comprising private practitioners and dental surgeons working in public and private institutions. The first part of the questionnaire included the demographic details of the dental practitioner, while the second part explored the knowledge, attitude, and practices toward oral tissue biopsies. Results: All GDPs (100%) believed that it was important to perform biopsies for the diagnosis of oral lesions. Eight-two per cent maintained that it should be done for all premalignant, malignant, and cystic lesions, while 18% suggested that it should be performed only in premalignant and malignant lesions, Twenty-six performed the biopsy on their own. Regarding the knowledge of various biopsy methods, 78% were aware of all biopsy techniques. Reasons quoted for not performing biopsy were the lack of experience (38%), lack of confidence (12%), and inadequate patient cooperation (12%). About 96% of dentists felt the need to update their knowledge regarding oral lesions and biopsy procedures with the preferable use of information. Conclusion: The GDPs enrolled in this study were adequately aware of oral screening and biopsy procedures but felt reluctant to perform them, which suggests that dental education programs are needed for GDPs in oral precancer/cancer detection as well as screening and diagnostic procedures.

Keywords: Differential diagnosis, histopathology, oral lesions, tissue specimen

How to cite this article:
Aishwariya S. Attitudes of general dental practitioners toward biopsy procedures – A survey. Int J Soc Rehabil 2020;5:21-5

How to cite this URL:
Aishwariya S. Attitudes of general dental practitioners toward biopsy procedures – A survey. Int J Soc Rehabil [serial online] 2020 [cited 2024 Feb 25];5:21-5. Available from: https://www.ijsocialrehab.com/text.asp?2020/5/2/21/331471

  Introduction Top

Biopsy technique is a diagnostic procedure which involves the removal of tissue from the affected area in the living organisms for microscopic examination and providing an appropriate diagnosis.[1] The diagnoses of many of the oral lesions require additional investigative procedures, out of which biopsies play an important role. Biopsy and subsequent tissue examination help in diagnosing the histological characteristics, level of differentiation, and the extent of the suspected lesion. Although dental practitioners may arrive at the clinical diagnosis of a lesion with various diagnostic tools, it is conventionally confirmed by histopathological examination.[2] Oral biopsies are indicated in:

  • White lesions (leukoplakia, lichen planus, leukoedema)
  • Red lesions (erythroplakia, atrophic lichen planus)
  • Vesiculobullous lesions (pemphigus, pemphigoid)
  • Soft tissue lesions (fibroma, mucocele)
  • Lesions on gingiva (pyogenic granuloma, gingival enlargement) and periapical cyst.[3]

Dentists are the first to encounter such changes in the oral cavity, they should take the responsibility to counsel, diagnose, and effectively treat the condition in its initial stages.[4] Dental professionals should detect and recognize oral lesions and inform the patient accordingly so as to provide early diagnosis and treatment. Although certain patients are not convinced with the biopsy procedures for some reasons, it should be worth convincing the patient by informing the benefits of an early diagnosis of a lesion. General dental practitioners (GDPs) must therefore be well versed in performing simple oral biopsies to diagnose oral lesions, preserving tissue specimens, and generating the subsequent report.[5],[6] Despite the benefits of performing a biopsy, it is observed that the practice of oral biopsy is not as widespread in dental practice predominantly due to the unfamiliarity of the procedure and its documentation.[7] Early identification of oral cancerous lesions reduces rates of morbidity, mortality, and mutilation; increases the quality of life; and lowers treatment costs.[8] Incidence of oral cancer is rising in most countries, with squamous cell carcinoma accounting for 95% of oral cancers, and it is associated with avoidable etiological risk factors.[9],[10] Awareness, clinical findings, and the experience of a dentist form the basis for successful judgment and diagnosis of a particular condition.[11] Oral lesions may be overlooked due to a lack of awareness of the disease or the presence of subclinical changes in a clinically innocuous oral mucosa.[12] However, in spite of the wide range of information available from routine oral biopsy and histopathological examination, biopsy procedures remain unpopular among GDPs. Therefore, the aim of the study was to explore the knowledge, attitudes, and practices of GDPs toward biopsy procedures.

  Materials and Methods Top

A self-designed questionnaire was administered to a convenient sample size of 50 dentists comprising private practitioners and dental surgeons working in public and private institutions. The first part of the questionnaire included demographic details such as the age, sex, and professional qualifications of the GDP, while the second part explored the knowledge, attitudes, and practices toward the diagnosis of oral lesions and performance of oral biopsies. The questionnaire comprising a total of 21 questions was distributed among the practitioners.

The questions were devised to obtain information on:

  • Awareness about the importance of biopsies in oral lesions
  • Knowledge and practical skills in diagnosing lesions and knowledge about biopsy of oral lesions
  • Knowledge of tissue handling and preservation of the samples
  • Reasons for not performing the procedures
  • Proximity to an oral pathologist.

  Results Top

Among the 50 GDPs, 23 males and 27 females participated in the survey. All GDPs (100%) believed that it was important to perform biopsies for the diagnosis of oral lesions.About 76% (n = 38) of GDPs did not perform biopsies in their clinical practice except for the remaining 24% (n = 12), as seen in [Figure 1].
Figure 1: Percentage of dentists who perform biopsies

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On asked about the question regarding lesions that required biopsy, 82% maintained that it should be done for all premalignant, malignant, and cystic lesions, while 18% suggested that it should be performed only in premalignant and malignant lesions [Figure 2]. On asked about what they do for lesions requiring biopsy, 48% (n = 24) of GDPs employed a specialist to perform the biopsy, while 24% (n = 12) referred their patients to a higher center. The remaining 26% (n = 13) performed the biopsy on their own (2%) claimed that they referred their patients to super specialty centers and 24% said that they would either call a specialist or refer them to a higher center based on the condition of the lesion [Figure 3].
Figure 2: Percentage of lesions that require biopsies

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Figure 3: Percentage of dentists who prefer to perform biopsies or when referred to specialists

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Regarding the question about their knowledge of various biopsy methods, as in [Figure 4], 78% (n = 39) were aware of all biopsy techniques. However, only 14% (n = 7) were aware of excisional biopsy, 6% were aware of only incisional biopsies, and 2% were only aware of fine-needle aspiration.
Figure 4: Percentage of awareness of various biopsy techniques

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The common reasons quoted for not performing biopsy was that 38% said it was due to the lack of experience, 12% of GDPs said it was due to lack of confidence to interpret the results for the particular lesion, and 12% reported that it was due to inadequate patient cooperation for the biopsy procedures [Figure 5]. The questionnaire also sought the opinion regarding the preservation of the specimen after removal of the tissue, of which 62% (n = 31) believed that preservation in formalin was the most ideal technique, while 38% (n = 19) agreed that the tissue sample could be preserved both in saline and formalin as seen in [Figure 6].
Figure 5: Representation of reasons for avoiding biopsy procedures

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Figure 6: Representation of biopsy sample preservation

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Majority of GDPs (96%) dentists felt the need to update their knowledge regarding oral lesions and biopsy procedures with the preferable use of information via journals, the Internet, and workshops, which is shown in [Figure 6].

  Discussion Top

Biopsies play a prime significance in diagnosing oral lesions[4] and there have been conflicting suppositions concerning if GDPs can perform biopsies. Certain GDP think that performing incisional and excisional biopsies for suspicious lesions will help in early and accurate diagnosis,[4],[5],[6] while others contend that those suspicious lesions should have to be instantly referred.[5],[6] Although most dentists prefer to refer biopsy cases to a specialist or a referral center, most believed that routine biopsies are well within the scope of a GDP as this would provide direct access to prompt management. Most GDPs who took part in a study (91.4%) believed that biopsy is a vital surgical procedure for an accurate diagnosis with commonly observed lesions that include cysts, benign and premalignant lesions, and malignant tumors. In addition, lesions in the oral cavity are much more accessible compared with lesions in other sites. In a study,[4] 97% of students agreed that family history plays an important role in oral cancer and thus the importance of performing a biopsy was unanimously agreed upon by all dentists to arrive at a conclusive diagnosis of various oral lesions. Boyle[5] suggested that the degree of qualification had little to do with the ability to perform a biopsy. In this survey, 26% of respondents performed biopsies on their own which was higher than those reported by Cowan et al.[7] who observed about 12% in Northern Ireland and 15% by Diamanti et al.[8] in Manchester. A study by Warnakulasuriya and Johnson[9] found that 21% of dental specialists in the United Kingdom and Seoane et al.[10] revealed that 24.5% of GDPs perform biopsies in Northwest Spain, while in Norway, Berge[11] found that 56% of dental specialists endeavored to perform a biopsy. In the current study, 48% of GDPs either called a specialist or referred the patient to a higher center.

This was lesser than those reported by Wan and Savage[12] in Brisbane where it was seen that 76.2% of GDPs referred their biopsy cases to a specialist. This could be due to a few variables such as the dread of medicolegal complexities, newness to the biopsy strategy, absence of confidence in individual analytic abilities, misguided judgment that suggests the need for expert opinion, or that the GDP may not be prepared to advise the patient that he has a disease. About 78% of GDPs, however, were familiar about excisional, incisional, and FNAC types of biopsies. The rest were aware of only one or other of the biopsy techniques. This clarifies the requirement for the GDP to be more compatible with biopsy strategies and their signs and contraindications. This would help them to settle on the sort of biopsy required in singular cases.[10],[11] The most commonly used fixatives were formalin, glutaraldehyde, and alcohol.[12] A study by Murgod et al.[1] stated that after the removal and before sending for analysis, (53.73%) practitioners rightly knew that it had to be sent in formalin, while (29.85%) believed that it could be stored in saline and 11.94% believed it could be preserved in alcohol.[8] In this study, 62% believed that the tissue sample should be preserved in formalin, while 38% stated that either saline or formalin could be used for preservation. This is an important aspect in biopsy procurement for clinicians as tissues that are not safeguarded legitimately produce artifacts which hamper diagnosis.[13],[14],[15] Histopathological examination of 967 biopsy specimens revealed that 43% of clinical diagnoses made by dental surgeons were incorrect in a study by Franklin and Jones[14] who estimated that 85% of dentists in their region did not send biopsies for histological analysis. The rationale for this could be that the excisional biopsy of lesions they consider to be clinically apparent such as mucoceles, fibromas, or periapical granulomas may only be considered for treatment. Thus, altered tissue after removal from the oral cavity should be sent for histopathological examination to arrive at a final diagnosis.[14] In doubtful conditions, the patient should be referred to a specialist with expertise in the diagnosis and management of oral lesions. In a study, it was observed that 89% of dentists did not think histopathologic analysis was required for all biopsied lesions and also stated that 48.09% of GDPs do not examine mucosal lesions on routine basis ignoring the fact that early detection has better prognosis for the patient.[15] Incipient lesions are easily detected in the oral cavity because of accessibility of oral cavity for examination and detection. Both the patient and the professional are associated with causes underlying a delay in definitive diagnosis.[16] In many cases, patients are unaware of the presence of early asymptomatic lesion or they just ignore the condition by taking self-medication.

In a study, it was found that 91.4% of dentists appreciated the diagnostic importance of oral biopsy, while only (19.8%) indicated that they perform an oral biopsy in their daily practice.[17] This aspect was also noticed by Wan A and Savage NW[12] where 58.1% of GDPs did not feel competent to undertake any biopsies mainly due to lack of experience and practical skills, Diamanti N[9] reported 25% of GDPs said they did not feel confident to perform biopsies.

In certain studies, it was stated that when GDPs were asked how they intended to update their knowledge, 59% of them preferred to attend workshops or CDE programs, 22% of them by attending conferences, 10% of them through Internet, and 9% of them through journals.[18],[19],[20] However in our study, 96% of dentists felt the need to update their skill-set regarding oral lesions and biopsy procedures, which they believed could be enhanced by aids such as journals, online content, conferences, and workshops. From several studies, it was concluded that there is a need for including clinical abilities workshops when instructing on oral biopsy techniques, as it is a supplementary but essential educational resource and supervised clinical procedure to be performed on real patients.[21],[22]

  Conclusion Top

With the exponential growth of dental science, dentists need to update their practices according to the best available scientific evidences. It is suggested that the frequent use of biopsy in dental practice will reduce the number of successful lawsuits brought for delay or failure to diagnose. The role of GDPs and histopathologist in the evaluation of tumor specimens has become complex in the last 10–20 years and will continue to develop in the decade ahead, thus proper diagnostic aids should serve the purpose of diagnosis such conditions. Dental practitioners are not well informed about the diagnostic importance and need for biopsy procedures. There may be a fear factor working in the minds of dentists about losing the patient who has been presented with a chief complaint unrelated to his mucosal lesion, if in case a biopsy procedure is advised or performed, or even if the patient is referred to a specialist for managing such a lesion. Knowledge about recent methodology in diagnosis, treatment, and precaution measures in oral cancer is very essential for improving the quality of life in patients with oral cancer. To help GDPs detect suspicious oral lesions, continuing dental education programs pertaining to the practical aspects of oral cancer should be conducted.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Murgod V, Angadi PV, Hallikerimath S, Kale AD, Hebbal M. Attitudes of general dental practitioners towards biopsy procedures. J Clin Exp Dent 2011;3:418-23.  Back to cited text no. 1
Kumar MP, Harshini AK. Knowledge and awareness about oral cancer among undergraduate dental students. Asian J Pharm Clin Res 2016;9:167-7.  Back to cited text no. 2
López-Jornet P, Camacho-Alonso F, Molina-Miñano F. Knowledge and attitudes about oral cancer among dentists in Spain. J Eval Clin Pract 2010;16:129-33.  Back to cited text no. 3
Mota-Ramírez A, Silvestre FJ, Simó JM. Oral biopsy in dental practice. Med Oral Patol Oral Cir Bucal 2007;12:504-10.  Back to cited text no. 4
Boyle PE. Who should take the biopsy? Oral Surg Oral Med Oral Pathol 1955;8:118-22.  Back to cited text no. 5
Porter SR, Scully C. Early detection of oral cancer in the practice. Br Dent J 1998;185:72-3.  Back to cited text no. 6
Cowan CG, Gregg TA, Kee F. Prevention and detection of oral cancer: The views of primary care dentists in Northern Ireland. Br Dent J 1995;179:338-42.  Back to cited text no. 7
Diamanti N, Duxbury AJ, Ariyaratnam S, Macfarlane TV. Attitudes to biopsy procedures in general dental practice. Br Dent J 2002;192:588-92.  Back to cited text no. 8
Warnakulasuriya KA, Johnson NW. Dentists and oral cancer prevention in the UK: Opinions, attitudes and practices to screening for mucosal lesions and to counselling patients on tobacco and alcohol use: Baseline data from 1991. Oral Dis 1999;5:10-4.  Back to cited text no. 9
Seoane J, Valera-Centelles PI, Ramírez JR, Cameselle-Teijeiro J, Romero MA. Artifacts in oral incisional biopsies in general dental practice: A pathology audit. Oral Dis 2004;10:113-7.  Back to cited text no. 10
Berge TI. Oral surgery in Norwegian general dental practice – A survey. Extent, scope, referrals, emergencies, and medically compromised patients. Acta Odontol Scand 1992;50:7-16.  Back to cited text no. 11
Wan A, Savage NW. Biopsy and diagnostic histopathology in dental practice in Brisbane: Usage patterns and perception of usefulness. Aust Dent J 2010;55:162-9.  Back to cited text no. 12
Kondori I, Mottin RW, Laskin DM. Accuracy of dentists in the clinical diagnosis of oral lesions. Quintessence Int 2011;42:575-7.  Back to cited text no. 13
Franklin CD, Jones AV. A survey of oral and maxillofacial pathology specimens submitted by general dental practitioners over a 30-year period. Br Dent J 2006;200:447-50.  Back to cited text no. 14
Avon SL, Klieb HB. Oral soft-tissue biopsy: An overview. J Can Dent Assoc 2012;78:75.  Back to cited text no. 15
Kaur R, Sircar K, Singh S, Rastogi V. Noninvasive diagnostic aids in the screening of oral cancer – A review. JOHS 2012;3:9-13.  Back to cited text no. 16
Bataineh AB, Hammad HM, Darweesh IA. Attitude toward oral biopsy among general dental practitioners: Awareness and practice. J Orofac Sci 2015;7:19-26.  Back to cited text no. 17
  [Full text]  
Anandani C, Metgud R, Ramesh G, Singh K. Awareness of general dental practitioners about oral screening and biopsy procedures in Udaipur, India. Oral Health Prev Dent 2015;13:523-30.  Back to cited text no. 18
Sunil A, Mohan A, Mathew J, Mukunda A, Nair A. Attitudes of general dental practitioners toward biopsy procedures. Oral Maxillofac Pathol J 2017;8:9-15.  Back to cited text no. 19
Nazar SA, Umamaheswari TN. Awareness of early detection and prevention of oral cancer among dentists – A review. IOSR JDMS 2014;13:10-2.  Back to cited text no. 20
Anuja N, Sherlin HJ, Anandan S, Mani NJ, Malathi N. Subclinical changes of oral mucosa in Hansen's disease – A histopathological and immunohistochemical study. Biol Med 2011;3:31-42.  Back to cited text no. 21
Seoane J, Varela-Centelles P, Esparza-Gómez G, Cerero-Lapiedra R, Seoane-Romero JM, Diz P. Simulation for training in oral cancer biopsy: A surgical model and feedback from GDPs. Med Oral Patol Oral Cir Bucal 2013;18:e246-50.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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