KNOWLEDGE OF ORAL BIOPSY PROCEDURE AMONG DENTAL INTERNS AT A TERTIARY HOSPITAL IN EASTERN NEPAL

Various diagnos�c procedures are available to reach a diagnosis in case of oral lesions. Biopsy is one of the important tools for conﬁrmatory diagnosis. It becomes impera�ve not only for den�sts but future den�sts to have adequate knowledge regarding oral biopsy procedures


Introduc on
Various diagnos c procedures are available to reach a diagnosis in case of oral lesions. Biopsy is one of the important tools for confirmatory diagnosis. It becomes impera ve not only for den sts but future den sts to have adequate knowledge regarding oral biopsy procedures.

Objec ves
To assess the knowledge of oral biopsy procedure among dental interns.

Methodology
A web-based cross-sec onal study was conducted among interns at College of Dental Surgery, B.P. Koirala Ins tute of Health Sciences. A ques onnaire was prepared and Google Form link was shared with the signed-up par cipants via messaging apps; Viber and Whats App. The descrip ve sta s cs were calculated using Microso Excel 2016.

Result
Out of 54 par cipants, 53 (98.15%) and 50 (92.5%) of the interns knew about incisional and excisional biopsy respec vely. Only 27 (50%) of them responded that every lesion should be sent for histopathological examina on. Only 25 (46.3%) of the interns were aware that the removal of ssue by laser or electrosurgery can introduce artefacts or ssue distor on and 27 (50%) responded that punch biopsy generally produces few artefacts within the biopsied sample. Seventy seven percent of the interns responded that volume of the fixa ve should be two mes the volume of the biopsy specimen, while 15 (27.78%) responded that normal saline could be used as a fixa ve.

Conclusion
The present study revealed, dental interns had a good understanding regarding oral biopsy and also highlighted the need for further training and modifica ons in curriculum.

INTRODUCTION
The Greek words bios, which means "life," and opsis, which means "vision," were combined to form the English word 1 biopsy. Biopsy is a valuable diagnos c tool for confirming 2 many oral condi on or disease. Failure to iden fy the pathology will delay mely interven on proper care and 3 could have serious consequences. Oral biopsies is important as it aid in both diagnosis and the classifica on of 4 oral lesions.
Care must be taken during the biopsy process because any mistake or error while doing it could lead to an inaccurate 2 histopathological diagnosis of the lesion. A biopsy site selec on, local anaesthe c administra on techniques, the surgical technique used to take the biopsy, appropriate size and depth of the ssue, and the subsequent fixa on technique all affect the quality of the biopsy sample and hence the histopathology slide interpreta on. The pathologist can make the correct diagnosis with the help of an accurate and per nent clinical descrip on of the lesion 2 along with a good biopsy sample. Therefore, to execute an effec ve oral biopsy, one has to have some basic technical exper se. The dental professional should be knowledgeable about the oral biopsy procedures and challenges faced during the biopsy. In light of this, the study was planned to evaluate the knowledge of dental interns regarding oral biopsy.

METHODOLOGY
A web-based cross-sec onal study was conducted among interns of the same batch at College of Dental Surgery, B.P. Koirala Ins tute of Health Sciences (BPKIHS), Dharan, Nepal from October to December, 2021. Total popula on census sampling was used. The study was approved by Ins tu onal Review Commi ee, BPKIHS (IRC/2094/20). A semistructured pro forma was prepared and modified based on 6 relevant literature. It consisted of socio-demographic data and four sec ons having 19 close-ended items on oral biopsy procedure with three op ons: "Yes," "No," and "Do not know." The Google Forms were created using docs.google.com/ forms, and the link was shared with the signed-up par cipants via messaging apps Viber and WhatsApp. The completed ques onnaires were exported to Microso Excel 2016 and Sta s cal Package for the Social Sciences so ware (version 21) was used to produce descrip ve sta s cs such as frequency and percentage in order to analyse the data. The findings were presented as tables and graphs.

RESULTS
A total of 54 interns responded to the ques onnaire, of them 37 (68.52%) were females, and the mean age of the respondents were 24±1.012 years (Table 1).  Out of 54, 45 (83.33%) par cipants responded that in case of mul ple samples of a lesion, each sample should be submi ed in a separate, clearly labelled container (Table 3). Only 25 (46.3%) of the interns were aware that the removal of ssue by laser or electrosurgery can introduce artefacts or ssue distor on and 27 (50%) responded that punch biopsy generally produces few artefacts within the biopsied sample ( Figure 1).

DISCUSSION
Evidence-based treatment choices and therapeu c outcomes are becoming increasingly important in the prac ce of modern den stry and medicine. Clinically, oral biopsies must be performed by a den st in order to diagnose oral lesions. The oral biopsy procedure is a competence skill that could be learned and gained exper se with me. The dental surgeon performing the biopsy is responsible for obtaining enough ssue and handling it properly so that the sample is sent to the pathologist in a state that is suitable for addi onal processing and analysis. In order to avoid misiden fica on of the lesions, den st should be able to perform biopsies but they also need to be aware of a variety of factors impac ng 2 the histopathologic interpreta on of an oral biopsy result. Almost every intern have the knowledge of incisional and excisional biopsy which is in contrast to the study done by Sunil et al where 63% of den sts were familiar with 7 incisional and excisional biopsy. Half of the par cipant responded that every lesion should be sent for histopathological examina on which is in contrast to a study done by Azizzadeh et al where 62.6% of dental students and 100% den st agreed to this fact that histopathological assessment of each abnormal oral ssue sample taken is necessary, while study done by Thete et al only 10% were 8,9 agreed to this. A study done by Sunil et al showed that only 11% of den st think that every lesion should be send for 7 histopathological examina on. According to the American Academy of Oral and Maxillofacial Pathology, any aberrant/abnormal ssue should be quickly submi ed for 10 microscopic assessment and analysis. Regardless of how certain the clinician is of the diagnosis, any abnormal ssue taken from the oral cavity should be sent for histological 11 analysis. One out of four par cipants were unaware that oral mucosa biopsies needed to be at least 3 mm in diameter and 2 mm deep. Mucosal biopsies must be at least 3 mm in diameter and 2 mm deep, while they must be deeper in cases of suspected squamous cell carcinoma and oral pre-malignant lesions due to thicker epithelium and hyperkeratosis. In these circumstances, 4-5 mm should be the minimum 12 required depth. Approximately nine out of ten par cipants responded that biopsy should be taken from the edge of the lesion in case of suspected malignancy. It would be preferable to biopsy the lesion and some nearby clinically normal epithelium if the 13 goal of the biopsy was to rule out suspected malignancy. Nine out of ten par cipants responded that margin of the surrounding normal ssue is required in case of excisional biopsy. Smaller lesions less than 1 cm in diameter that appear benign on clinical examina on, should be treated with excisional biopsy. The en re lesion along with 2-3 mm 14 of the normal surrounding ssue are removed. Nine out of ten par cipants responded that toluidine blue or direct fluorescence helps to highlight the most severe or significantly changed ssue for biopsy. Toluidine blue is an easily available, economical, meta-chroma c dye known to bind DNA of dividing cells. In various studies, it has been men oned to stain poten ally-malignant and malignant 15,16 cells but not normal mucosa. It binds to cells with high DNA and RNA concentra ons because of its affinity for 17 nucleic acids. Similarly, the loss of normal ssue auto fluorescence in dysplas c and neoplas c ssues is also visible using direct fluorescence method; these altera ons are the result of a series of histological and biochemical 18 changes. They can therefore be used as a supplemental tool to look for early, subtle clinical changes. Almost all par cipants (98.15%) responded that incorrect handling of ssue following its removal introduces artefacts or render ssue non-diagnos c, also excessive trac on of the ssue causes the lacera on or crushing of the specimen and significantly damage the epithelium or connec ve ssue. Poor handling of biopsy at any point could lead to a non-diagnos c biopsy and force the pa ent to undergo the 19 procedure again. Only half of the interns in our survey responded that punch biopsy o en results in few artefacts in the biopsied sample. Fragmenta on of the sample may happen during punch biopsy while removing the ssue 20 sample from the underlying base using scissors. As a result, dental surgeons need to take extra care while cu ng ssue for punch biopsy procedures.  Less than half of the par cipants responded that the removal of ssue by laser or electrosurgery can introduce artefacts or ssue distor on. Heat produced by electrosurgery and laser surgery results in a fulgura on artefact, which alters the epithelium and connec ve ssues. In fulgura on artefact, epithelial cells appear to be separated from one another, and their nuclei show signs of hyper 11,[21][22][23] chroma sm, spindled and palisaded structure.
These altera ons mislead the lesion's histology because they resemble the presence of epithelial dysplasia since margins are crucial in cases of malignancy, invasion, or pre- 24 malignancy. These changes may modify both the diagnosis and the appropriate course of treatment. More than three-fourths of the interns responded that the volume of the fixa ve should be two-mes the volume of the sample taken. Since ssue autolysis occurs quickly following resec on, the biopsy specimen should be put in a 13,25. fixa ve solu on right away At least 10 mes the volume of the ssue samples should be used as fixa ve for the 26 biopsy specimen. The clinicians frequently overlook this crucial component of biopsies. When ssue is not properly maintained, it creates numerous artefacts that make it [27][28][29] difficult for the pathologist to make an accurate diagnosis. Surprisingly, more than one fourth of the dental interns believed that the specimen can be fixed in normal saline and similar findings were reported in other studies done on 7,[30][31][32] general dental prac oners.
Unfortunately using saline as a fixa ve has nega ve impact on ssue and produces artefact in the ssue lead to inconclusive or not appropriate diagnosis, maybe promp ng the doctor to do another 30 biopsy, adding to the pa ent's distress. Six out of ten responded that biopsy specimens shrink a er formalin fixa on. If the specimen is too small, such as a thin strip of oral mucosa, the ssue will curl and flex as a result of the formalin fixa on process and it will be challenging to posi on the specimen correctly during the embedding 28 process. This may lead to difficulty in making histological diagnosis. We have seen throughout me how quickly den stry is expanding and making new advancements each day. But we are not confident when it comes to oral biopsy, which is in fact the gold standard for the detec on/diagnosis of oral cancer and other oral diseases. Many conferences rela ng to various dental procedures have been held by various organiza ons, but few have been arranged for fundamental procedures like biopsy. Even during the COVID era, dental educa on has con nued unabatedly in the form of online webinars, but only a small percentage of these sessions were observed to concentrate on the technical aspects of 32 biopsy procedures. Oral cancer and oral poten ally malignant lesions are of great concern in our country. The length and quality of pa ents' lives will undoubtedly be improved by early and prompt diagnosis which is possible only if the future den sts have adequate knowledge regarding biopsy procedure. Present study revealed that dental interns have fair understanding and knowledge regarding oral biopsy procedure and s ll lack a few crucial perspec ves regarding biopsy fixa on and handling. Oral biopsy is the part of undergraduate curriculum, therefore dental interns must not only know where, when and how to perform the oral biopsy, the preserva on of the ssue and also the ability to manage the subsequent sample is important. Considering the small sample size, the results may not be generalizable to the en re popula on of dental interns in Nepal. However, our findings highlighted the need for knowledge improvement in this area.

CONCLUSION
Dental interns have a good understanding of oral biopsy. However, the knowledge of the interns highlighted the need for further training programs and curriculum modifica on.