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.