Biopsy and diagnostic histopathology in dental practice in Brisbane: usage patterns and perceptions of usefulness

Authors


Dr Neil W Savage
Oral Medicine and Pathology
School of Dentistry
The University of Queensland
200 Turbot Street
Brisbane QLD 4000
Email: n.savage@uq.edu.au

Abstract

Background:  Biopsy procedures and diagnostic histopathology are rarely used by general dental practitioners (GDPs) compared with dental specialists. The aim of this study was to investigate the usage patterns and views of GDPs and specialists in Brisbane on these procedures.

Methods:  An analysis was carried out on 1027 oral biopsy accessions at a private pathology laboratory. A survey was distributed to 200 GDPs and dental specialists inquiring about their use of and views on biopsy and diagnostic histopathology. An analysis was carried out on 327 and 95 biopsies performed at a private oral medicine practice and at the University of Queensland School of Dentistry, respectively.

Results:  The majority (76.2%) of GDPs surveyed referred all oral lesions requiring biopsy to a specialist, rather than undertaking biopsy themselves. Although most GDPs recognized the importance of biopsy, a large proportion (58.1%) did not feel competent in undertaking the procedure due to concerns of inadequate experience and practical skills.

Conclusions:  Many dental practitioners believe that GDPs should be able to undertake simple biopsies of benign lesions, however more undergraduate and postgraduate training in biopsy and diagnostic histopathology is necessary to promote a greater use of these procedures.

Abbreviations and acronyms:
ENT

ear, nose and throat

GDPs

general dental practioners

Introduction

The use of biopsy procedures and diagnostic histopathology services by general dental practitioners (GDPs) is limited.1–8 Previous surveys of oral pathology diagnostic services suggest the dominant users are dental specialists, with only a small proportion of biopsy accessions from GDPs.2–4 The explanation may lie in the small number of oral lesions seen by GDPs and requiring biopsy, resulting in a lack of experience with both biopsy procedures and diagnostic histopathology.1 Therefore, although most GDPs undertake routine screening of the oral mucosa,1,5,6,9–11 there are few who proceed to the biopsy procedure on either a routine or selective basis1,5–8 and referral to a specialist is the preferred diagnostic route following the detection of suspicious oral lesions.1,5,6,8,12

Given the range of information available from routine histopathology, it is interesting that biopsy procedures do not attract greater use. Biopsies provide an important tool in the diagnostic process of oral lesions which, by clinical examination alone, can often be difficult and inaccurate.13–16 Of particular importance is the contribution of biopsy and histopathology to the early detection of premalignant and malignant lesions.1,13,16,17 Failure to biopsy may lead to persistence of a misdiagnosed malignant lesion or other serious pathology, resulting in an unfavourable downstream course for the patient and the attending clinician.1,13,16,17 There are a number of reasons for the limited use of diagnostic histopathology services by GDPs. The primary reasons include a lack of perceived value in obtaining a tissue specimen for histopathological diagnosis,13 inadequate practical skills in performing biopsy and fear of diagnostic error.1 Secondly, the majority of any obtained specimens may be discarded rather than submitted for examination and histological reporting.2 This transforms the procedure from investigational to a final treatment protocol and ignores the opportunity to obtain additional supportive information from the procedure.

Many authors believe that it is well within the scope of practice of GDPs to carry out simple biopsies of benign lesions.1,14,18 This would provide a direct patient benefit with accelerated diagnosis and entry into treatment. However, it seems that GDPs still feel unprepared to carry out biopsy procedures due to an inadequate level of education and experience acquired during undergraduate training.1,19,20 Previous studies have also stressed both the GDP’s lack of experience and familiarity with oral lesions and the consequent need for better education in oral medicine, clinical oral pathology and diagnostic procedures.1,12

The aim of this study was to assess the current use of soft tissue biopsy procedures in general and specialist dental practice in Brisbane by investigating the dominant users of private diagnostic histopathology services, the usage patterns and attitudes of GDPs and dental specialists to biopsy and diagnostic histopathology, and the range of lesions biopsied by dental practitioners. This information will assist in determining whether a higher level of importance should be placed on biopsy and diagnostic histopathology in undergraduate and postgraduate dental programmes to ultimately promote a greater use of these procedures in dental patient management. It was hypothesized that soft tissue biopsy procedures are mainly performed by certain dental specialists with their use by GDPs being very limited due to a lack of perceived value and inadequate experience in this area.

Materials and methods

This study consisted of three parts:

  • 1 An analysis was completed on 1027 biopsy accessions over a one-year period from March 2007 to March 2008 at a private pathology laboratory in Brisbane. Information recorded from accession records included the specimen source (GDP or specialist), type of specialist and histological diagnosis. Histological diagnoses were then grouped into diagnostic categories.
  • 2 A purpose-specific 17 question survey, excluding demographics, was sent with a reply-paid envelope to 200 general and specialist dental practitioners in Brisbane to obtain information on: (a) demographic data; (b) current use of soft tissue biopsy and diagnostic histopathology services; (c) personal experience with and views on soft tissue biopsy and diagnostic histopathology; (d) views on the future position of soft tissue biopsy and diagnostic histopathology in dental practice. Dental practitioners were selected from the Yellow Pages® telephone directory entries.
  • (3) An analysis of biopsy procedures undertaken over a two-year period between June 2006 and June 2008 at both a private oral medicine practice in Brisbane (n = 327) and the Oral Medicine Clinic at the University of Queensland School of Dentistry (n = 95) was carried out. Information recorded included the biopsy site, type of biopsy procedure, clinical diagnosis and histological diagnosis. Histological diagnoses were then grouped into diagnostic categories. A further analysis of these 422 biopsy cases determined the proportion of biopsies suitable for GDPs to undertake. This involved evaluating the complexity of each case based on the biopsy site and clinical diagnosis of the lesion. Simple sites included the buccal mucosa, labial mucosa, gingiva, alveolar mucosa and hard palate which can be accessed relatively easily with minimal risk. Complex sites included the floor of the mouth, soft palate and tongue, as well as the lip vermillion due to its aesthetic importance. Simple lesions included only true benign lesions such as polyps, papilloma, epulides, mucocoeles and fibromas. Any potentially malignant or premalignant lesions including those which presented as leukoplakia, erythroplakia, chronic ulceration or pigmented lesions were considered complex lesions, as well as cysts and bone lesions.

All data were recorded in a de-identified form into Microsoft Excel and analysed using the OStats 3.1 software to obtain counts and proportions. The results were then summarized in tabular format without the need for further statistical analysis.

Results

Biopsy accessions at a private pathology laboratory

During the one-year period, 1027 biopsy specimens were received by the Brisbane laboratory. Specialists submitted 915 (89.1%) of these cases and GDPs contributed 112 (10.9%). Among the specialists, the most cases were received from oral medicine specialists, followed by oral and maxillofacial surgeons, endodontists, periodontists, ear, nose and throat (ENT) surgeons and paedodontists. The number and percentage of cases received from each type of practitioner is summarized in Table 1.

Table 1.   Cases received by the laboratory from each type of practitioner
Type of practitionerCases received n (%)
Oral medicine specialists410 (39.9)
Oral and maxillofacial surgeons298 (29.0)
Endodontists126 (12.3)
GDPs112 (10.9)
Periodontists72 (7.0)
ENT surgeons6 (0.6)
Paedodontists3 (0.3)

A total of 131 different histological diagnoses were obtained from the specimens received which were grouped into 13 diagnostic categories. Overall, the most common diagnostic category was benign connective tissue lesions (200 or 19.5%), followed by dentoalveolar lesions (179 or 17.4%), cysts of the cervicofacial region (166 or 16.2%), benign epithelial lesions (127 or 12.4%) and gingival and periodontal lesions (93 or 9.1%). The most frequently encountered diagnosis was fibroepithelial polyp (164 or 16.0%), followed by periapical granuloma (143 or 13.9%), apical periodontal cyst (70 or 6.8%), reactive hyperkeratosis (59 or 5.7%) and dentigerous cyst (51 or 5.0%). Of the cases submitted by GDPs, the most common diagnostic category was dentoalveolar lesions (32 or 28.6%), followed by benign connective tissue lesions (26 or 23.2%), cysts of the cervicofacial region (19 or 17.0%), gingival and periodontal lesions (14 or 12.5%) and benign epithelial lesions (7 or 6.3%). The most frequently encountered diagnosis was fibroepithelial polyp (22 or 19.6%), followed by periapical granuloma (21 or 18.8%), apical periodontal cyst (15 or 13.4%), chronic periodontitis (5 or 4.5%) and reactive hyperkeratosis (4 or 3.6%). In total, 26 malignancies (22 squamous cell carcinomas, two polymorphous low-grade adenocarcinomas, one verrucous carcinoma and one melanoma) were diagnosed during the year, accounting for 2.5% of all cases, all of which were received from specialists (13 from oral medicine specialists and 13 from oral and maxillofacial surgeons).

Survey of general and specialist dental practitioners

Of the 200 surveys distributed, 79 (39.5%) were returned, 44 (55.7%) from GDPs and 19 (24.1%) from specialists. The remaining 16 (20.3%) participants did not indicate their GDP or specialist status. The demographic details of participants are summarized in Table 2. Factors such as gender, year of graduation and type of practice did not seem to have a significant influence on survey responses.

Table 2.   Demographic details of survey participants
 GenderYear of graduation (BDSc)Type of practitionerType of practice
Distribution n (%)Male 45 (57.0)Pre-1960 1 (1.3)GDP 44 (55.7)Private 43 (54.4)
 Female 15 (19.0)1960–1969 5 (6.3)Oral and maxillofacial surgeon 5 (6.3)Private and public 9 (11.4)
 Unreported 19 (24.0)1970–1979 16 (20.3)Periodontist 5 (6.3)Public 6 (7.6)
  1980–1989 18 (22.8)Endodontist 4 (5.1)Unreported 21 (26.6)
  1990–1999 13 (16.5)Prosthodontist 2 (2.5) 
  Post-2000 9 (11.4)Orthodontist 1 (1.3) 
  Unreported 17 (21.5)Oral medicine specialist 1 (1.3) 
   Paedodontist 1 (1.3) 
   Unreported 16 (20.3) 

The frequency at which practitioners saw oral lesions requiring biopsy is summarized in Table 3. Most GDPs noted oral lesions requiring biopsy at least once a year or at least once in the last five years, whereas most specialists reported seeing them at least once a month or at least once a week. Nine (64.3%) practitioners who saw lesions monthly and all who saw them weekly were specialists. The specialists who saw lesions every week included three oral and maxillofacial surgeons, an oral medicine specialist and a paedodontist. The specialist with a zero lesions return was an orthodontist.

Table 3.   Frequency of seeing oral lesions, management of oral lesions and frequency of performing biopsies
 All practitioners n (%)GDPs n (%)Specialists n (%)
How often do you see an oral lesion requiring biopsy?
 Never3 (3.8)2 (4.5)1 (5.3)
 At least once in the last 5 years16 (20.3)11 (25.0)2 (10.5)
 At least once a year41 (51.9)28 (63.6)2 (10.5)
 At least once a month14 (17.7)3 (6.8)9 (47.4)
 At least once a week5 (6.3)0 (0)5 (26.3)
How do you routinely manage oral lesions requiring biopsy? (excluding those who reported never seeing lesions)
 Refer all cases to a specialist47 (61.8)32 (76.2)4 (22.2)
 Biopsy benign lesions only18 (23.7)8 (19.0)7 (38.9)
 Biopsy both benign and suspect malignant lesions8 (10.5)1 (2.4)6 (33.3)
 Other (e.g., biopsy lesions in readily accessible sites, biopsy larger suspect lesions)3 (4.0)1 (2.4)1 (5.6)
How often do you perform biopsies of oral lesions?
 At least once in the last 5 years8 (25.8)4 (40.0)0 (0)
 At least once a year9 (29.0)6 (60.0)2 (14.3)
 At least once a month10 (32.3)0 (0)8 (57.1)
 At least once a week4 (12.9)0 (0)4 (28.6)

The methods by which practitioners routinely managed oral lesions requiring biopsy are summarized in Table 3. The majority of GDPs referred all cases of oral lesions requiring biopsy to a specialist, with a small proportion performing biopsies of benign lesions and one who biopsied both benign and suspect malignant lesions. Most specialists on the other hand, biopsied either benign lesions only or both benign and suspect malignant lesions. Seven (38.9%) of the practitioners who biopsied benign lesions only and six (75.0%) who biopsied both benign and suspect malignant lesions were specialists. The specialists who biopsied both benign and suspect malignant lesions included five oral and maxillofacial surgeons and an oral medicine specialist.

Thirty-one (39.2%) practitioners surveyed had biopsied or routinely performed biopsies of oral lesions. Of these, 10 (32.3%) were GDPs, 14 (45.2%) were specialists and seven (22.6%) did not indicate their status. This shows that only 22.7% of GDPs undertook biopsies compared to 73.7% of specialists. The frequency at which these practitioners performed biopsies of oral lesions is summarized in Table 3. GDPs who undertook biopsies reported a rate of at least once a year or at least once in the last five years, whereas most specialists reported performing them at least once a month or at least once a week. The specialists who biopsied every month included three periodontists, two oral and maxillofacial surgeons, two endodontists and a paedodontist. The ones who biopsied every week included three oral and maxillofacial surgeons and an oral medicine specialist.

All of the 31 practitioners who performed biopsies submitted specimens for histopathological reporting, except for one GDP. The majority (40 or 83.3%) of practitioners who did not biopsy did not submit any tissues from their practice for histopathological reporting. Tissues most commonly submitted were gingival masses, followed by periapical pathology, gingival hyperplasia, denture hyperplasia, gingivectomy tissues and dental follicles.

Fifty-three (67.1%) and 43 (55.1%) practitioners reported only being taught theory for biopsy procedures and diagnostic histopathology, respectively during undergraduate training, with a smaller proportion having received practical experience in addition to theory and few having received neither. Only 24 (30.8%) and 20 (26.0%) practitioners, mainly specialists, had received any formal postgraduate training, including continuing professional development courses, in biopsy procedures and diagnostic histopathology respectively. Sixty-two (81.6%) and 61 (80.3%) practitioners surveyed viewed biopsy and diagnostic histopathology, respectively in patient management as being very important, a much smaller proportion as moderately important and very few as unnecessary. All practitioners who felt these procedures were unnecessary were GDPs.

Most GDPs (25 or 58.1%) did not feel competent undertaking any biopsies, a smaller proportion (17 or 39.5%) felt competent undertaking simple biopsies of benign lesions and only one (2.3%) undertook all biopsies. These responses contrasted with those of the specialists of whom most felt competent undertaking either all biopsies (9 or 47.4%) or simple biopsies of benign lesions (8 or 42.1%), with only two (10.5%) not feeling competent undertaking any biopsies. The specialists who felt competent undertaking all biopsies included five oral and maxillofacial surgeons, two endodontists, an oral medicine specialist and a periodontist. The specialists who did not feel competent undertaking any biopsies included an orthodontist and a prosthodontist. Of the 19 practitioners who received practical experience in biopsy procedures during undergraduate training, all except one felt competent to perform either simple biopsies or all biopsies. Similarly, only one of the 24 practitioners who had received formal postgraduate training in biopsy procedures did not feel competent to perform any biopsies.

The main concern of practitioners was lack of experience with biopsy procedures, followed by lack of practical skills, risk of producing a non-diagnostic specimen, risk of diagnostic error, risk of an intraoperative medical emergency and risk of litigation. Although concerns between GDPs and specialists were similar, GDPs were more concerned about a lack of experience and practical skills, whereas specialists were more concerned about producing a non-diagnostic specimen and diagnostic error. Of the specialists, only two (an endodontist and a prosthodontist) were concerned about a lack of experience with biopsy procedures and only one (a prosthodontist) was concerned about a lack of practical skills.

Sixty (76.9%) practitioners believed GDPs should be able to undertake simple biopsies of benign lesions, 11 (14.1%) felt GDPs should be able to undertake all biopsies, six (7.7%) believed GDPs should never undertake biopsies and one (1.3%) believed GDPs should biopsy if confident. Views were similar between GDPs and specialists.

Sixty-two (83.8%) and 54 (75.0%) practitioners agreed that a higher level of importance should be placed on biopsy procedures and diagnostic histopathology, respectively during undergraduate and postgraduate dental programmes. Fifty-two (73.2%) and 42 (61.8%) practitioners believed that more practical experience in biopsy procedures and diagnostic histopathology respectively is needed in current dental programmes. A smaller proportion indicated more theory and practical experience or more theory only, and a few either suggested other ideas or believed that no changes are needed to the current curricula. Sixty-seven (90.5%) and 61 (83.6%) practitioners agreed that a higher level of undergraduate and postgraduate training in biopsy and diagnostic histopathology, respectively would promote a greater use of these procedures in dental patient management. Sixty-four (85.3%) felt this would improve current management of oral lesions and patient outcomes. Ideas were similar between GDPs and specialists.

Biopsy procedures undertaken at a private oral medicine practice and at the University of Queensland School of Dentistry

During a period of two years, 327 and 95 biopsies were performed at a private oral medicine practice in Brisbane and at the Oral Medicine Clinic at the University of Queensland School of Dentistry, respectively. At both locations, biopsies were performed by oral medicine specialists only, explaining the high rate of concordance between clinical and histological diagnoses. At the two locations, a total of 61 different histological diagnoses were obtained from biopsy specimens. These were divided into the same diagnostic categories as for the laboratory accessions discussed previously. There were no significant differences with regards to diagnostic categories, diagnoses, biopsy sites and biopsy procedures between the two locations.

The most common diagnostic category was benign epithelial lesions, followed by benign connective tissue lesions, immune mediated lesions, gingival and periodontal lesions and benign pigmented epithelial lesions. The most frequently encountered diagnosis was fibroepithelial polyp, followed by epithelial hyperplasia, epithelial dysplasia, benign squamous papilloma and lichen planus. The most common biopsy site was buccal mucosa, followed by gingiva, tongue, labial mucosa and lip vermillion. The most frequent biopsy procedure undertaken was excisonal biopsy, followed by incisional biopsy and punch biopsy. These results are summarized in Table 4. Twenty-two malignancies (21 squamous cell carcinomas and one verrucous carcinoma) were diagnosed during the two years, accounting for 5.2% of all cases.

Table 4.   Biopsies undertaken at a private oral medicine practice and at the University of Queensland (UQ) School of Dentistry
Most common diagnostic categories n (%)Most frequently encountered diagnoses n (%)Most common biopsy sites n (%)Most frequent biopsy procedures n (%)
Benign epithelial lesions 108 (25.6)Fibroepithelial polyp 90 (21.3)Buccal mucosa 96 (22.7)Excisonal 289 (68.5)
Benign connective tissue lesions 99 (23.5)Epithelial hyperplasia 31 (7.4)Gingiva 78 (18.5)Incisional 72 (17.1)
Immune mediated lesions 43 (10.2)Epithelial dysplasia 28 (6.6)Tongue 78 (18.5)Punch 61 (14.5)
Gingival and periodontal lesions 42 (10.0)Benign squamous papilloma 26 (6.2)Labial mucosa 31 (7.3) 
Benign pigmented epithelial lesions 34 (8.1)Lichen planus 24 (5.7)Lip vermillion 29 (6.9) 

Of the 422 biopsies performed at the two locations, 131 (31.0%) involved simple sites and simple lesions, and were therefore suitable cases for GDPs to undertake. The other 291 (69.0%), of which 124 (29.4%) involved simple sites and complex lesions, 105 (24.9%) involved complex sites and complex lesions and 62 (14.7%) involved complex sites and simple lesions, were unsuitable cases for GDPs.

Discussion

The results of this study show that the dominant users of soft tissue biopsy procedures and diagnostic histopathology services in Brisbane are dental specialists, with only 10.9% of biopsy specimens submitted for histopathological reporting by GDPs. It is likely that this proportion of specimens was contributed by a small group of GDPs with a special interest in clinical oral pathology. The specialists who submitted the most specimens were oral medicine specialists and oral and maxillofacial surgeons. These findings coincide with those of Franklin and Jones,2 Williams et al.3 and Rich et al.,4 in which GDPs contributed 17%, 28% and 16% of biopsy specimens received by their pathology laboratories, respectively.

Over 50% of specimens submitted by GDPs were dentoalveolar lesions and benign connective tissue lesions, with the most common diagnoses being fibroepithelial polyp and periapical granuloma. All 26 cases of malignancies received by the laboratory during the year were from specialists, with no malignant lesion accessions from GDPs. Of the 31 cases of epithelial dysplasia, only one was submitted by a GDP. These findings also coincide with those of Franklin and Jones,2 Williams et al.3 and Rich et al.,4 which all showed the most common specimens submitted by GDPs to be reactive mucosal lesions (mostly fibroepithelial polyps) and periapical pathology (mostly periapical granulomas and cysts), with only a very small number of malignant and premalignant lesions. This suggests that the GDPs who perform biopsies are selecting appropriate cases to biopsy themselves and referring more complex or suspicious cases to a specialist.

From the survey, it is clear that GDPs do not encounter oral lesions requiring biopsy frequently, with most GDPs reporting seeing lesions at least once a year or at least once in the last five years, as opposed to specialists who tend to encounter oral lesions monthly or weekly. Similar findings were obtained by Diamanti et al.,1 in which 46% of GDPs saw lesions requiring biopsy annually and only 33% detected lesions on more than one occasion each year. Warnakulasuriya and Johnson5 found higher rates with 63% of GDPs noting oral lesions in one or more patients within the last 12 months prior to their study.

The majority (76.2%) of GDPs surveyed routinely managed oral lesions requiring biopsy by referring all cases to a specialist, with only a small proportion (19%) undertaking biopsies of benign lesions. Most specialists on the other hand, either biopsied benign lesions or both benign and suspect malignant lesions. Studies by Diamanti et al.,1 Warnakulasuriya and Johnson,5 Cowan et al.6 and Coulthard et al.8 showed that 55%, 74%, 37% to 62.1% and 84% of GDPs surveyed respectively referred all oral lesions to a specialist without further investigation.

Of the GDPs surveyed, only 22.7% had performed or routinely perform biopsies, compared with 73.7% of specialists. All of these GDPs reported either performing biopsies at least once a year or at least once in the last five years, as opposed to specialists who usually performed them on a monthly or weekly basis. Almost all practitioners who performed biopsies submitted specimens for histopathological reporting. However, most practitioners who did not perform biopsies also did not submit any tissues (e.g., periapical lesions, gingival tissues, denture hyperplasia) for histopathological reporting, even though routine histopathology of all soft tissues removed from a patient is indicated in order to obtain a definitive diagnosis of any presenting pathology. Studies by Diamanti et al.,1 Warnakulasuriya and Johnson,5 Cowan et al.6 and Seoane et al.7 showed that only 15%, 21%, 12% and 24.5% of GDPs surveyed respectively performed biopsies.

Over 50% of practitioners reported only being taught theoretical knowledge in biopsy procedures and diagnostic histopathology during undergraduate training, without having received any practical experience in these two areas. In addition, only a small proportion of practitioners had received any formal postgraduate training in biopsy procedures and diagnostic histopathology, with the majority being specialists. Notwithstanding this, over 80% of practitioners viewed biopsy procedures and diagnostic histopathology as being very important in patient management. The GDP’s lack of training in biopsy procedures was also shown in the study by Diamanti et al.,1 in which 39% of GDPs surveyed reported never being taught biopsy techniques.

Although the majority (58.1%) of GDPs did not feel competent to undertake any biopsies, a significant proportion (39.5%) felt competent to undertake simple biopsies of benign lesions. Conversely, almost all specialists felt competent to undertake either all biopsies or simple biopsies of benign lesions. The study by Diamanti et al.1 showed that 25% of GDPs surveyed did not feel competent in performing biopsies, but 60% felt competent in performing simple biopsies of benign lesions and believed that this would help accelerate the management of such lesions. Greenwood et al.19 found that only 21% of recently qualified dentists felt prepared to undertake soft tissue biopsies. It was interesting to find that almost all practitioners who had received practical experience in biopsy procedures during undergraduate training or had undertaken postgraduate training in biopsy procedures felt competent to perform either simple biopsies or all biopsies. This reflects the views of many authors who agree that the limited use of biopsy procedures and diagnostic histpathology is largely due to inadequate education in these areas1,19,20 and therefore GDPs who had been taught how to biopsy or had actually performed a biopsy during their undergraduate studies were more likely to undertake biopsy procedures in general practice.1,17,20,21

The main concerns of GDPs with regards to performing biopsies were a lack of experience and practical skills, whereas specialists were more concerned about producing a non-diagnostic specimen and diagnostic error. Despite these concerns, the majority (76.9%) of practitioners surveyed agreed that GDPs should be able to undertake simple biopsies of benign lesions, with only a small proportion (7.7%) believing that GDPs should never undertake biopsies. The study by Diamanti et al.1 revealed that 70% of oral and maxillofacial surgeons would discourage GDPs from undertaking biopsies due to concerns of a lack of practical skills in taking a representative sample and delays in referral. The remaining 30% of surgeons strongly believed GDPs should be competent in performing simple biopsies (excisional rather than incisional procedures) of benign lesions.1 Jephcott18 and Oliver et al.14 also agree that it is well within the scope of practice of GDPs to carry out simple excisional biopsies of small benign lesions such as polyps, papillomas, epulides, mucocoeles and fibromas. Performing simple excisonal biopsies in general practice provides the advantage of a reduced waiting time for the procedure and the results, as well as less travelling for the patient.1,18 On the other hand, suspected malignant or premalignant lesions such as leukoplakia, erythroplakia or chronic ulceration, or lesions whose nature is uncertain, should not be biopsied in general practice, but should be referred without delay to a specialist who will be undertaking the definitive treatment.1,2,14,18 If a lesion initially thought to be benign is biopsied and ultimately diagnosed as malignant or premalignant, appropriate referral to a specialist for urgent attention is critical.

The majority of practitioners surveyed agreed that a higher level of importance should be placed on biopsy procedures and diagnostic histopathology during undergraduate and postgraduate dental programmes, most suggesting that more practical experience should be added to the current curriculum in order to promote a greater use of these procedures in dental patient management.

The biopsies performed at a private oral medicine practice and at the University of Queensland School of Dentistry by oral medicine specialists produced a variety of diagnoses including a significant number of malignant and premalignant lesions which relied on histopathological evaluation of the biopsy specimen to establish a definitive diagnosis before appropriate treatment could be initiated. This further emphasizes the importance of biopsy and diagnostic histopathology in the management of suspicious lesions. Failure to biopsy may lead to the misdiagnosis of a malignant lesion or other serious pathology, resulting in the progression of the lesion to an advanced stage before treatment is initiated. It is completely acceptable for GDPs to refer patients requiring biopsy to a specialist for the procedure, as the need for biopsy is recognized and actioned rather than being delayed due to lack of clinical expertise or other reason.13 Of the 422 biopsies performed at the two locations, a significant proportion (31.0%) involved simple sites and simple lesions, suggesting that many patients present with oral lesions suitable for GDPs to biopsy.

The major limitations of this study were the small sample size of the survey due to time constraints and a poor participation rate. In addition, 20.3% of participants did not provide demographic details including whether they were a GDP or specialist, which caused some difficulty when comparing the two groups. Overall, the study supported the hypothesis that soft tissue biopsy procedures are mainly performed by certain dental specialists (oral medicine specialists and oral and maxillofacial surgeons, and to a lesser extent, endodontists and periodontists), with their use by GDPs and other specialists being very limited due to inadequate experience and education in the area. Despite this, the majority of dental practitioners recognize the importance of biopsy procedures and diagnostic histopathology in the management of patients who present with oral lesions and most agreed that with appropriate case selection, GDPs should be able to undertake simple biopsies of benign lesions. However, in order to promote a greater use of biopsy procedures and diagnostic histopathology in dental patient management, a higher level of importance first needs to be placed on these topics during undergraduate and postgraduate dental programmes to provide both general and specialist dental practitioners with the experience and practical skills necessary to carry out these procedures safely and confidently.

Acknowledgements

The authors gratefully acknowledge the generous assistance of Mrs Jenny Chaston in this project.

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