– Place the B forceps. The handle is pressed to open the forceps and put them into place; releasing the handle exerts spontaneous pressure on the tissue. The window enclosing the diseased tissue is surrounded by a 1-millimeter–high elevated ring that prevents the plates from slipping. This tissue is raised within the window, and the pressure produces ischemia, a fluid-depletion effect (Figure 2).

– Carry out asepsis within the window (using 0.12 percent chlorhexidine is suggested). Use anesthetic outside the window area.

– Section with a punch or a scalpel within the area of tissue for biopsy. The sectioned tissue, with little hemorrhage, is pushed out by pressure from the plain plate (a phenomenon called the "tissue plug" effect).

– Cut the base of the tissue sectioned in the step above. The B forceps enables the clinician to measure the depth of the sample before cutting.

– Place sutures.

– Remove the B forceps.

View larger version (103K): [in this window] [in a new window]   Figure 2. The B forceps positioned to take a biopsy specimen from the buccal mucosa. The slight prominence of exposed tissue is seen through the window. The fluid-depletion effect is created by the pressure of the forceps. (The B forceps is distributed by Laboratorios Bonfanti Gris, Madrid, Spain.)

We placed the first 42 patients in group A; they underwent biopsy with a conventional procedure with either a scalpel (group A1, 29 patients) or a 6-mm–diameter punch (group A2, 13 patients). We placed the next 42 patients in group B; they underwent biopsy of the buccal mucosa with a 6-mm–diameter punch and the B forceps.

The first 42 biopsy specimens (group A) were taken between 1983 and 1996, before the B forceps was designed. From 1996 forward, the biopsy specimens were taken with prototypes of the B forceps. The biopsies of the 42 patients in group B were performed between 1996 and 2005.

Histopathologic assessment. The pathologist (M.J.J.-T.) fixed the samples in formol with 10 percent buffer for a minimum of 24 hours, processed them and embedded them in paraffin by using conventional procedures. She made cuts of 5 micrometers. We decided to exclude specimens that were poorly oriented in the paraffin blocks.

The pathologist carried out a blind study of the histologic variables (without knowing to which group each case belonged). When selecting and evaluating the artifacts, we took into account criteria of previous authors such as Bernstein⁵ or Seoane and colleagues.⁶ The variables were as follows (the type of artifact and the classification used within each variable are indicated) (Figures 3 and 4):

View larger version (101K): [in this window] [in a new window]   Figure 3. Microscopic image of fragmentation (hematoxylin and eosin stain, x100 magnification).

View larger version (109K): [in this window] [in a new window]   Figure 4. Microscopic image of hemorrhage (hematoxylin and eosin stain, x200 magnification).

– fragmentation or breaking, in which the sample appeared totally or partially broken into two or more fragments (rated as none, superficial or deep);

– pseudocysts, spaces or cavities without lining (rated as none, superficial or deep [in submucosa or muscle]);

– "crushing," a term we used especially to refer to clamp marks (rated as none, superficial or deep [in submucosa or muscle]);

– fissures or tears, including detachment of connective epithelium but not including openings characteristic of hydropic degeneration of keratinocytes in the basal cell layer, openings characteristic of laboratory manipulation (such as cutting in the microtome) or openings caused by inadequate cutting of the sample (rated as none, superficial or deep [in submucosa or muscle]);

– hemorrhage (rated as none, at the edge of the sample or throughout the whole sample).

Statistical analysis. We used SPSS version 12.0 for Windows (SPSS, Chicago). We conducted a descriptive and inferential analysis, comparing the categorical and qualitative variables between groups A1 and A2 and between groups A and B by means of Pearson’s ² test. We considered a P value of less than .05 to be significant.

	RESULTS

TOP ABSTRACT SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Of the 84 patients, 13 were male (15.5 percent) and 71 were female (84.5 percent). The mean patient age was 54.51 years (range, 23 to 79 years; standard deviation, 13.768 years).

We found pseudocysts in only one case in group A. For the other four parameters, there were no significant differences between groups A1 and A2 (P < .05). Table 1 shows the comparative data for the two A groups.

	DISCUSSION

TOP ABSTRACT SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

In the case of OLP, which is characterized by the damage caused by lymphocytes in the keratinocytes of the basal cell layer of certain areas of the mucosa,⁸ the diagnosis is clinicopathological.² OLP has a high prevalence among the population, estimated at 0.2 to 1.9 percent worldwide.⁹ It often causes characteristic asymptomatic lesions, and the general dentist should be able to diagnose this disease during a routine exploration.

The conventional biopsy, because of its simplicity and the direct view and ease of access to the different oral structures, continues to be the principal test for the study of the different lesions of the oral mucosa. In certain situations, it should be a routine diagnostic method for the dentist^10,11 instead of other useful procedures, such as cytology,¹¹ the toluidine blue test,¹² fine-needle aspiration biopsy,¹² needle biopsy¹³ and oral brush biopsy,¹⁴ or more current procedures such as chemiluminescence.¹⁵ However, it is estimated that in the private general dental practices in Spain, the most time—18.2 percent—is devoted to surgery. Only 0.7 percent of this is dedicated to performing biopsies.¹⁰ The fact that the general dentist in Spain does not carry out biopsies of lesions in the oral mucosa routinely means that for dental patients with suspicious lesions, diagnosis of the disease is, at best, delayed.

The dentist often carries out extractions that occasionally can be complicated and that always are more complex than the simple, safe surgery involved in performing a biopsy of the oral mucosa. The above may be due, among other reasons, to the peculiarities of certain oral soft tissues. The dentist is accustomed to operating on the tooth, periodontium or bone, elements that are practically immobile and, therefore, are stable and safe in daily practice situations. On the other hand, the highly vascularized tongue, lips or buccal mucosa, all of which are unsupported by underlying bone, provide less security and visibility for the professional.

With the aim of obviating these drawbacks, we designed a forceps that allows the general dentist to perform an oral mucosal biopsy in a safe, efficient and quick manner and that, according to the results of our study, creates minimal artifacts during the acquisition of samples. The B forceps is based on the chalazion forceps (Moria Dugast, Paris), which is used in ophthalmology to hold the eyelid and in the mouth has been used almost exclusively for performing biopsies of the minor salivary glands of the lip.^4,16 Novice clinicians using the B forceps should be aware that the oral mucosa can move easily and that, therefore, an assistant may need to stabilize the area by means of an instrument or his or her fingers. Stabilization and traction techniques depend on the anatomical area in the oral cavity (lips, tongue or buccal mucosa) that is being treated. During surgical extirpation, controlling local bleeding caused by cutting in the vascular portions of the area can be challenging, because excess bleeding leads to poor visibility, which, in turn, may lead to suboptimal surgery and thereby complicate what should be a simple procedure.

Limitations in the use of the traditional forceps led us to the idea of designing the B forceps, which is more versatile. Thus, we created a prototype of the B forceps more than 10 years ago.¹⁷ Its characteristics, the pros and cons regarding its use and the surgical technique for its use have been described previously,^18,19 as have its advantages over the chalazion forceps.²⁰

One specialist recorded and performed biopsies for all 84 patients, which minimized the problems that would have been associated with the clinical handling of patients by different specialists. With the same objective, a single pathologist carried out the histopathologic analysis and the study of artifacts for all 84 patients.

The statistical analysis of our results showed no significant differences within group A between the biopsies performed with a scalpel and those performed with the 6-mm–diameter punch but without aid of the B forceps. Moule and colleagues,²¹ in a study of oral biopsies, found more artifacts in biopsy specimens taken with a scalpel than in those taken with a punch. However, in a more recent experimental study that involved pigs’ tongues, Seoane and colleagues²² found no differences between these two instruments when analyzing crushing, fragmentation and pseudocysts. On the other hand, they found more fissures in the samples taken with a scalpel.

When comparing all cases in group A (without B forceps) with the cases in group B (with B forceps and 6-mm–diameter punch), we found significant differences. Group B showed less fragmentation, fewer fissures and fewer hemorrhages than did group A.

Pseudocysts were found in only one subject in group A and one subject in group B. The comparative study of crushing did not reveal any significant differences between groups A and B. The hemorrhages found in group B were related to deeper samples. Logically, the B forceps is useful not only for performing biopsies in the oral mucosa, but also for performing biopsies of the minor salivary glands¹⁹ and small swellings such as mucoceles¹⁸ or even in the resection of oral leukoplakias via mucosectomy. When the lesion is larger than the window of the open plate, the area can be resected and the forceps moved to work on the remainder of the lesion. Likewise, the B forceps can be used in dermatology, gynecology or any other specialty requiring small soft-tissue extirpations or biopsy.

Limitations in the use of the B forceps are related to its prehensile properties. It cannot be used on the gingiva, palate or areas of difficult access such as the base of the tongue.

	CONCLUSION

TOP ABSTRACT SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The study described here compares the taking of biopsy specimens with and without the B forceps and confirms previous clinical results^18–20 owing to, among other causes, the fluid-depletion and tissue-plug effects. We concluded the following about the B forceps:

– It improves visibility (acting as a tractor).

– It describes the field (for purposes of anesthesia and asepsis).

– It creates an area of ischemia (by pressure).

– It allows measurement of the depth of the sample (the tissue-plug effect).

– It allows access to the base of the sample.

– It reduces the time needed for the intervention.

– We observed no undesirable effects of using it.

We found the B forceps to be a useful tool for the clinician in performing a biopsy, with no undesirable effects. The statistical analysis showed that at the anatomopathological level, the B forceps kept artifacts to a minimum and that statistically significant differences existed between samples taken with the B forceps and those taken traditionally in regard to fragmentation, fissures and hemorrhages.