Intraoral Biopsy Techniques for Pemphigus & Pemphigoid

Hi! My name is Mark Mintline, and I am an oral and maxillofacial pathologist.

And I would like to talk to you today about how to perform intraoral biopsies of vesiculobullous lesions. My goal is to talk to you a little bit about biopsy techniques and the laboratory testing of blistering diseases so that your comfort level for performing biopsies goes up.Pemphigoid and pemphigus are rare autoimmune blistering diseases that often first present in the mouth.

Unfortunately, often there are delays in diagnosis. On average, it takes 6-10 months for a person with pemphigus vulgaris to get a final diagnosis.

And patients with pemphigus vulgaris or mucous membrane pemphigoid see an average of 5 healthcare providers before getting a final diagnosis.Biopsies can quicken diagnosis times and save lives.When taking a biopsy, our goal is to obtain a representative tissue sample with intact epithelium.

For blistering diseases, both conventional H&E histology and direct immunofluorescence (DIF) are needed.Pemphigus vulgaris is an acquired autoimmune disease that leads to intraepithelial separation.Mucous membrane pemphigoid is a chronic autoimmune disease that results in subepithelial separation.When taking a biopsy to evaluate for pemphigus and pemphigoid it is important to: 1) sample from a representative site, 2) not damage the tissue, and 3) appropriately transport the specimen.In order to obtain a piece of representative intact epithelium, we should biopsy adjacent or perilesional to an active or new blister.Biopsies of bullae, erosions, and ulcers will likely not yield intact epithelium and therefore will be non-diagnostic for the pathologist.A biopsy of an ulcer will lead to a non-diagnostic specimen.In general, two punch biopsies are preferable: one punch for H&E and one punch for DIF.Punch biopsies are less likely to tear tissue and are less technique-sensitive than shave or larger biopsies.You may choose to divide one biopsy into two pieces, but make sure to maintain orientation of the specimen and not to compress, pinch, or crush the specimen.Perform the biopsies directly adjacent to, but not including, an active blister.After performing the biopsies, place the tissue samples into the appropriate transport media.

For H&E, place the specimen into formalin. For DIF, place the specimen into Michel’s of Zeus medium.In general, it is easier to obtain specimens from the anterior part of the mouth, but if possible avoid tissue samples of the marginal gingiva.

Non-specific inflammation from dental plaque may obscure the microscopic findings.The tissue is extremely fragile. Please take care not to compress, pinch, or crush the specimen.Direct immunofluorescence is a laboratory method to detect antigens and autoantibodies.

It requires a specific transport medium (Michel’s or Zeus solution). Please note that formalin-fixed tissue cannot be processed for direct immunofluorescence.In direct immunofluorescence, the specimen is sectioned, stained with fluorescein-conjugated antibodies to IgG, IgM, C3, and fibrinogen, then they're examined for specific staining patterns.In this case, we took two perilesional biopsies: one for routine histopathology and one for direct immunofluorescence.

The DIF showed IgG deposition at the basement membrane zone. Combined with clinical and histopathologic findings, the patient was diagnosed with mucous membrane pemphigoid.##SummaryThank you for watching this video on oral biopsies techniques.

In summary, biopsies lead to diagnoses and save lives. Intraoral biopsies are technique-sensitive.

The main goal is to get a piece of representative intact epithelium. Lastly, separate biopsies for H&E and DIF are often needed for final diagnosis.

Thank you. membrane pemphigoid.

Thank you for watching this video on oral biopsy techniques in summary biopsies, lead to diagnosis and save lives in tororo, biopsies are technique sensitive.

The main goal is to get a piece of Representative intact. Epithelium.

Leslie separate biopsies for Asian. Endif are often needed