Tag Archives: Clinical Skills

Dentist Performing Jaw Bone Biopsy - Online Postgraduate Dental Education

How to Perform a Jaw Bone Biopsy

Dentist Performing Jaw Bone Biopsy - Online Postgraduate Dental Education

What is a jaw bone biopsy?

When you use the term “bone biopsy,” this could mean you are taking a piece of bone or you are taking tissue that resides inside a bone.

There are two approaches for a bone biopsy.  A closed/needle bone biopsy involves inserting a needle through the skin/mucosa directly into the bone, and an open bone biopsy requires making an incision to expose an area of the bone. Continue reading How to Perform a Jaw Bone Biopsy

Dentist Holding An Aspirating Needle for an Oral Cavity Cyst Aspiration Procedure

How to Perform an Oral Cyst Aspiration and Cytologic Smear

Dentist Holding An Aspirating Needle for an Oral Cavity Cyst Aspiration Procedure

Cyst Aspiration

A cyst is a membranous sac or cavity of abnormal character containing fluid.

Indications for an Oral Cyst Aspiration

For a jaw bone cyst lesion or any large soft tissue oral mucogingival cyst, aspirate the cyst aspiration.  To help diagnosis of erythematous, pseudomembranous candidiasis, or suspected herpetic lesions use exfoliative cytology.

Continue reading How to Perform an Oral Cyst Aspiration and Cytologic Smear

Two Dentists Performing an Oral Cavity Punch Biopsy on Soft Tissue - USC Postgraduate Dentistry Master's and Certificate Programs

How to Conduct an Oral Cavity Punch Biopsy

Two Dentists Performing an Oral Cavity Punch Biopsy on Soft Tissue - USC Dentistry Online

What is a punch biopsy?

An oral cavity punch biopsy is considered the primary technique to obtain diagnostic, full thickness skin specimens.  It is performed using a circular blade or trephine attached to a pencil-like handle.  The instrument is rotated down through the epidermis and dermis, and into the subcutaneous fat.  The punch biopsy yields a cylindrical core of tissue that must be gently handled (usually with a needle) to prevent crushing the artifact at the pathologic evaluation. Continue reading How to Conduct an Oral Cavity Punch Biopsy

Dentist Performing an Excisional Oral Biopsy in a Patient's Mouth

How to Perform an Oral Biopsy

Dentist Performing an Excisional Oral Biopsy in a Patient's Mouth

A biopsy is defined as the sampling or removal of tissues or liquids from the body for examination, in order to determine the existence or cause of a disease.  A biopsy is strongly recommended for most of the lesions that persist for more than two weeks which interferes with oral function, or does not improve by removing the local irritants.

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6 Basic Etiologic Categories for an Oral Lesion

Whenever you see an oral lesion, train yourself by using the diagnostic sieve to list out possible clinical differential diagnoses:

  1. Developmental (Congenital)
  2. Inflammatory/Infection
  3. Neoplastic
  4. Traumatic
  5. Autoimmune/Allergic
  6. Oral manifestation of systemic disease

Related Reading: The Dentist’s Guide to Oral Pathology of Vesicular Ulcerative Conditions

Don’t have time to read The Dentist’s Guide to Oral Pathology of Vesicular Ulcerative Conditions?  Download the checklist!

 

6 Reasons Why It Is Important to Have a Differential Diagnosis

  1. It helps you determine when to perform the biopsy: Is it urgent?
  2. It helps you determine how to perform the biopsy: Punch, Incisional or Excisional biopsy? What instruments do I need?
  3. It is how doctors approach diagnosis of an unknown disease.
  4. It will demonstrate to the patient, third party, and pathologist that you have included all the clinical possibilities.
  5. It generally leads to better decision-making.
  6. It also helps to prevent errors in judgment and misdiagnosis or failure to diagnose.

 

What kinds of biopsies are available?

1. Punch Biopsy

Punch biopsies are commonly used in dermatology for sampling of skin lesions.  It is also used for gingival biopsies especially for cases of pemphigus vulagaris or mucous membrane pemphigoid.

2. Excisional Biopsy

An excisional biopsy removes the entire lesion and it is both a therapeutic as well as a diagnostic procedure.  Excisional biopsies are most commonly used for lesions of 1 cm or less, for even larger benign lesions to avoid multiple surgeries, or when complete removal is possible without significant morbidity.

3. Incisional Biopsy

An incisional biopsy involves taking a small portion of the lesional tissue for diagnostic purpose.  Incisional biopsies are commonly used:

  • When a lesion is large enough that definitive removal for histologic diagnosis would produce significant morbidity.
  • When necessary to convince a patient that serious pathology exists although the patient may not agree or may be asymptomatic.
  • When malignancy is highly suspected and biopsy is performed for confirmation and rapid diagnosis rather than attempting to remove the cancer completely with clear margins.

Additional Reading: Infectious Lesions of the Oral Cavity: Histoplasmosis & Mucormycosis

 

What are the contraindications for an oral biopsy?

There are no contraindications for a biopsy when the risk of doing nothing outweighs the risk of the surgical procedure.  In some instances, contraindications to surgical biopsy may exist due to underlying systemic conditions such as severe and uncontrolled hypertension.  In such situations, the procedure can be delayed until appropriate precautions are in place such as:

  • Asking the physician to lower the patient’s elevated blood pressure with medications.
  • Asking the physician to give the patient clotting factor or stop anticoagulant medications if the patient has an elevated INR.
  • Treating the local infection with antibiotics.
  • Referring to the adequate institute to perform the biopsy in a high risk cardiovascular disease patient (e.g. hospital).

If you are confident the lesion is a malignancy, refer to the surgeon that is likely to manage, such as head and neck surgeon or oncologist.

Note: do not try to excise a malignancy during a biopsy as there will be no lesion left for the surgeon to assess for further treatment.

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Step-by-Step Oral Biopsy Procedure

Dentist Performing an Excisional Biopsy of Oral Soft Tissue in the Mouth

1. Select the Area to Biopsy

Prior to the procedure, you must have an idea of how, where, and what kind of procedure you are going to perform.

When pemphigus vulgaris or mucous membrane pemphigoid are suspected, the biopsy should be performed at the edge of the lesion to include both lesional and normal tissues because there may not be much normal tissue left at the center of the lesion due to a very thin epithelium or ulcer.

If the lesion is a precancerous lesion like leukoplakia or an early Squamous Cell Carcinoma (SCC) then you can biopsy just the center of the lesion and leave the border alone so that the lesion can be excised in total at a future appointment.  You can also elect to biopsy a small part of the margin of the lesion and the normal tissue so that the pathologist can compare the normal and abnormal tissue.

Note: Early SCC may look like an erythroplakia or leukoplakia.

Related Reading: Oral Pathology of Oropharyngeal Squamous Cell Carcinoma

 

2. Prepare the Instruments and Environment

The basic instruments you need for a soft tissue biopsy include:

  1. Local anesthetic cartridge and syringe
  2. Scalpel: Blade handle with the blade or a disposable scalpel (No. 15 and 12 blades are most commonly used)
  3. Tissue forceps with and without teeth
  4. Retractors
  5. Needle holder and suture (4-0 or 5-0 silk sutures are commonly used intraorally)
  6. Scissors
  7. Gauze
  8. Curved forceps, Bite block (as needed)
  9. Specimen bottle with fixing solution and biopsy data sheet

 

3. Administer Anesthesia

Use both topical and local anesthesia in an attempt to obtain less or no pain to the patient during the procedure.  In general, patients are afraid and nervous for any surgical procedures.  The more pain control you achieve, the greater the chance of success.  For large lesions, anesthesia blocks are preferable.  Also, if you are planning to perform an incisional biopsy, do not infiltrate inside the lesion as that may create artifacts (vacuolation).

Do Not Rush to the Next Step

Take enough time for the local anesthesia to work.  You will not only achieve good pain control, but excellent hemostasis as well, which will ultimately make the procedure easier.

 

4. Make a Wedge-Shaped Incision

For both incisional and excisional biopsies, a wedge-shaped incision is desired in an attempt to have a clean, desirable closure.  The incision should extend beyond the suspected depth of the lesion.

Biopsy Incision Tips

  • If possible, include the adjacent normal tissue.
  • Do not use small strokes with the scalpel.  Incisions should be continuous.  Small strokes will destroy the cell alignment of the tissue and the orientation.
  • Do not cut the specimen to see what might be inside. The pathologist may want to ink the specimen to establish the margins.
  • For excisional biopsies, take enough representative tissue without damaging the tissue integrity.
  • Be aware of adjacent anatomy to avoid unnecessary tissue damage.
  • Be cautious not to crush the specimen with tweezers or suction the specimen. Accidental suctioning of tissue is very common. (Educate the assistant well prior to the procedure).

Note: Length of incisions should be parallel to natural resting lines when possible to optimize esthetics.

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5. Remove and Transfer the Specimen

A. Use One Bottle Per Specimen

Do not mix specimen unless it is a connective tissue mass that came out in several parts.

B. Fill with Formalin

The volume of formalin should be at least 20 times the volume of the specimen.  If immunofluorescence analysis is desired, the specimen needs to be placed in a different solution called Michel’s solution.

C. Label the Bottle

Each container should be identified with the patient’s name, clinician’s name, date and the site of the biopsy.

D. Stabilize the Tissue

Place mucosal or epithelial biopsies on a small rigid piece of paper before placing in the formalin bottle to prevent the tissue from rolling around itself and collapsing which would make it more difficult for the pathologist to orient and interpret the specimen.

E. Place an Orientation Suture (if required)

When performing a biopsy of a suspicious lesion (possible tumor), place an orientation suture in the specimen (one suture will be enough) so the pathologist can tell you which margins are clear or not.

F. Transfer to the Transport Media

Put the sample immediately into the transport media, not on gauze or on the surgical tray where it may dry out or undergo significant autolysis, and make sure the cap is tight so it does not spill while being transported to the pathology lab.

G. Fill out the Biopsy Data Sheet

Provide the pathologist with clinical and background information including: clinical appearance, duration, symptoms, pertinent medical history, risk factors, and clinical differential diagnosis.

If possible, submit copies of clinical or radiographic images with the biopsy to give the pathologist the ability to correlate clinical, radiographic, and histopathologic findings.

Lastly, do not draw on or circle the lesion on photographs or radiographs.  The pathologist will be able to see the abnormality without you pointing it out and possibly distorting the image.

 

6. Obtain Hemostasis and Wound Closure

Best hemostasis can be obtained by direct pressure unless you damaged a larger vessel.

For patients who will definitely need follow-up, use non-resorbable silk sutures.  One suture should be placed every 3-5mm’s, and the wound should be sutured without tension to avoid dehiscence.  Similarly, do not pull the knot too tight for soft tissue suturing.

Note: Do not try to achieve hemostasis by using anesthesia.

 

7. Provide Post-operative Instructions

Review the aftercare instructions with the patient and preferably a family member to ensure adherence and understanding.

A. Pain

If the procedure site was large or if the patient is already experiencing pain, prescribe NSAIDs or stronger analgesics (e.g. Vicodin).  For small procedures, patient can take OTC analgesics such as a 200-mg tablet of Ibuprofen (Advil, Motrin) 3 times a day with food, or a 325-mg tablet of Acetaminophen (Tylenol) every 6 hours, or as needed.

For any biopsy, instruct the patient to take one tablet of analgesic before the anesthesia wears-off.  If you do not hold any analgesics in your office, you should advise the patient to bring in the medication which they usually take when they have pain at the day of biopsy.

B. Bleeding

Bleeding might occur especially during the first few days: Patient can apply direct pressure for 10 minutes using a gauze or tissue to stop bleeding. If it continues to bleed, instruct patient to contact the clinic.

C. Swelling and Bruising

Swelling can happen as a healing process. Educate the patient that peak swelling is generally the 3rd or 4th day after the procedure and then will gradually subside. Bruising is less common for soft tissue biopsies, but might happen depending on the extent of the procedure and the patient’s age (e.g. older) or immunity.

D. Smokers

For smokers, educate them to stop smoking during the time when tissue is healing (at least a week).

E. Additional Biopsies

Lastly, inform the patient the possibility of another biopsy in the future depending on the diagnosis the pathologist makes.  If the histologic diagnosis does not seem correct with your clinical impression, talk to the pathologist personally and decide if you need another biopsy or not.

 

Further Reading

 

Earn an Online Postgraduate Degree in Orofacial Pain and Oral Medicine

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Trigger Point Mapping - Orofacial Pain Dentist Using Pincer Technique to Identify Referral Pain

Trigger Point Mapping: Theory & Step-by-Step Technique

Trigger Point Mapping - Orofacial Pain Dentist Using Pincer Technique to Identify Referral Pain

What is a trigger point?

A trigger point is due to sensitized sensory nerves within a taut band of a muscle that when squeezed generates local and referred pain.

Trigger Point ComplexThe cause of a taut band is a hyperactive motor nerve branch, which generates sustained contraction in the muscle fibers attached to the motor endplate that the nerve branch supplies.

A sustained ongoing contraction in a portion of the muscle (taut band) squeezes the blood vessels within the band and this diminishes perfusion and causes the build-up of metabolic by-products of the contraction in the muscle.

This metabolic waste aggravates and sensitizes the sensory nerve fibers (type IV or C-fibers) nearest the hyperactive motor end plate and these nerves will demonstrate mechanical allodynia (tenderness to light palpation pressure) and spontaneous pain.

Related Reading: How to Measure Orofacial Pain With a Muscle Tenderness Exam

Because these sensory nerve fibers fire spontaneously they start to cause central sensitization of the 2nd order neuron in the brain stem or spinal cord and when strongly stimulated causes referred pain.

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What’s the difference between a latent and active trigger point?

An active trigger point is painful spontaneously and produces referred pain when squeezed.  A latent trigger point is not painful spontaneously and produces referred pain only when squeezed.

 

What’s the difference between an active trigger point and an acupuncture point?

An active trigger point is located in a painful muscle.  An acupuncture point(s) are specific locations on the body along known acupuncture meridians.

 

Why do you get referral pain palpating an active trigger point?

Referred pain occurs via a process called convergence referral.

Convergence means that several sensory nerves coming from different but adjacent myotomes and dermatomes in the patient converge on a single, 2nd-order pain transmission neuron.  This neuron is usually a wide, dynamic range neuron and thus receives a variety of pain-specific nerve fiber input and low and high threshold mechanosensory (non-pain) input.

Related Reading: How to Conduct a Cranial Nerve Examination

Referral occurs because the constant firing of a pain sensory fiber from a trigger point changes the response characteristics of the 2nd-order pain transmission neuron making it more sensitive to lower threshold input.  Because of this, input that is not painful is misinterpreted as pain and pain is then felt in areas that are not being directly stimulated (thus “referred” pain sensations).

 

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Diagnostic Criteria of a Myofascial Trigger Point

  1. Patient has a regional pain complaint
  2. Identification of a palpable taut band
  3. There is an exquisitely tender trigger point along the length of a taut band on palpation
  4. Palpation of trigger point elicits referred pain
  5. There is some degree of restricted range of motion of the involved muscle
  6. Palpation of the trigger point usually should reproduce the clinical pain complaint
  7. A local twitch response may be elicited by transverse snapping of the trigger point
  8. Alleviation of pain by stretching the trigger point or anesthetic injection into the trigger point

Related Reading: How to Perform a TMJ Injection

 

Proper Trigger Point Palpation Technique

  1. Use your finger tips to move skin over muscle, not across the skin
  2. Palpate across the muscle fibers (perpendicular to the fiber direction), not along the fibers, to identify a taut band
  3. Apply about 2 kg (= 4.5 lbs) of pressure during palpation
  4. Use pincer technique to identify taut bands if the muscle can be picked up
  5. Compress points in the taut band for at least 3 seconds to ask about referral

Don’t forget to map trigger points and referral patterns.  On a head and neck diagram indicate:

  • The location of all trigger points
  • The pain intensity of each trigger point
  • The direction/pattern of all referred pain phenomena

Related Reading: Closed Lock Mobilization: TMJ Exercises & Stretches

 

Postgraduate Orofacial Pain and Oral Medicine Master’s Degree

Learn more about diagnosing, treating, and managing neuropathic pain disorders by enrolling in Herman Ostrow School of USC’s online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine.

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Gingival Cold Test - Woman with Dental Cheek Retractor

How to Administer a Gingival Cold Test

Gingival Cold Test - Woman with Dental Cheek Retractor

This test is utilized when you have a focal, intraoral, probable neuropathic pain disorder involving a branch of the trigeminal nerve with palpable gingival allodynia/hyperalgesia and no obvious, local dental pathology exists such as tooth fractures, periapical lesions, or non-vital dental pulp (irreversible pulpitis).

The goal of this test is to see if pain can be provoked and then lingers with a topical cold application to suspected neuropathically altered gingival tissues.  If the pain is not provoked and lingers less than 10 seconds then it is less likely neuropathic pain. Continue reading How to Administer a Gingival Cold Test

Female Dentist Holding a Needle Preparing for a TMJ Injection- Online Postgraduate Dentisty Degree Training in Orofacial Pain

How to Perform a TMJ Injection

Female Dentist Holding a Needle Preparing for a TMJ Injection- Online Postgraduate Dentisty Degree Training in Orofacial Pain

TMJ injections are performed with corticosteroid and anesthetic to produce a two-fold effect: one reduce inflammation with the corticosteroid (triamcinolone acetonide) and two produce anesthesia or pain relief using lidocaine 2% without epinephrine.  Corticosteriod is best used when swelling and pain are secondary to trauma, with acute OA flare ups, and DDNR cases. Continue reading How to Perform a TMJ Injection

Muscles of the Lower Jaw - How to Measure Muscle Tenderness to Diagnose Orofacial Pain

How to Measure Orofacial Pain With a Muscle Tenderness Exam

Muscles of the Lower Jaw - How to Measure Muscle Tenderness to Diagnose Orofacial Pain

In this article, we review ways to assess muscle tenderness and pain.  Common abnormalities of the masticatory muscle include injection induced myositis, myofascial taut band, trigger point, hypertrophy, spasms, etc.

Note: Prior to each procedure, introduce yourself to the patient, explain the purpose of the examination, obtain consent, and be sure to meet infectious control standards.

Relative Tenderness Assessment

With all muscles that you palpate there are two methods.  First is the relative tenderness assessment which is done using a standard anatomic location and a standard pressure level.  The locations are described below for each muscle.  The pressure to be used is 2 kg of pressure with one finger for 2 seconds.  While palpating, ask the patient to rate the pressure as none, mild, moderate or severe.

Note:  calibrate yourself periodically with a pressure algometer to make sure you are palpating with the right pressure on both hands.

Related Reading: Reliability and Usefulness of the Pressure Pain Threshold Measurement in Patients with Myofascial Pain

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Trigger Point Assessment

The second aspect of a muscle palpation assessment is to palpate across the muscle with your fingers to identify any taut bands.  This involves sliding the overlying skin back and forth across the muscle.  Taut bands will be evident if it is present and once you find the band, you move up and down the band applying firm pressure while asking the patient to report the most tender point in the band.  Once found, this point needs to be compressed for 5 seconds (with 2 kg pressure) to see if the pain radiates or refers.

Related Reading: TMJ Assessment: Jaw Range of Motion, Noise, and Tenderness

1. Deep Masseter Muscle Palpation

This site is anterior and inferior to the lateral condyle pole, posterior to the posterior edge of the superficial masseter, and beneath the zygomatic arch.  Palpate the deep masseter for tenderness using a none, mild, moderate or severe scale.

2. Superficial Masseter Muscle Palpation

This site is beneath the zygomatic arch and the muscle is angled back towards the angle of the mandible.  Palpate the superficial masseter for tenderness using a none, mild, moderate or severe scale.

3. Anterior Temporalis Muscle Palpation

The anterior temporalis muscle is best palpated at the hair line and opposite the eyebrow.  Palpate the anterior temporalis for tenderness using a none, mild, moderate or severe scale.

4. Posterior Temporalis Muscle Palpation 

This site is just above the pinna or the ear and its direction is posterior from the coronoid process.  Palpate the posterior temporalis for tenderness using a none, mild, moderate or severe scale.

Related Reading: How to Conduct a Cranial Nerve Examination

5. SCM (Sternocleidomastoid) Muscle Palpation

This site is from the manubrium of the sternum (sterno-) and the clavicle (cleido-), and has an insertion at the mastoid process of the temporal bone of the skull.  Palpate the sternocleidomastoid muscle for tenderness using a none, mild, moderate or severe scale.

6. Temporalis Muscle Tendon Palpation:

The temporalis muscle tendon is at the coronoid process just beneath the zygomatic process and is accessed by having the mouth open.  Palpate the temporalis muscle tendon for tenderness using a none, mild, moderate or severe scale.

7. Lateral Pterygoid Muscle Functional Exam

Test the lateral pterygoid muscle for proper function.  The lateral pterygoid muscle cannot be palpated but you can assess the function of this muscle by asking the patient to protrude the jaw.

8. Medial Pterygoid Palpation

Palpate the medial pterygoid muscle both intraorally and extraorally.   The origin of the medial pterygoid muscle is located on the inner surface of the pterygoid plate behind the maxilla.

Postgraduate Orofacial Pain and Oral Medicine Master’s Degree

Learn more about diagnosing, treating, and managing orofacial pain by enrolling in Herman Ostrow School of USC’s online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine.

 

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Sabouraud Agar Culture Test Results - Histoplasmosis Fungal Infection

How to Perform an Agar Slant Culture Test for Fungal Infections

Sabouraud Agar Culture Test Results - Histoplasmosis Fungal Infection
Agar Slant Cultures of Histoplasmosis

The Sabouraud Agar Slant Culture test is used when fungal overgrowth of the oral tissues is suspected, and is used to confirm the diagnosis of a fungal infection.  Other adjunctive methods for the diagnosis of oral candidiasis include exfoliative cytology using PAS-stain or KOH and biopsy.

Related Reading: Infectious Lesions of the Oral Cavity: Histoplasmosis & Mucormycosis

What is in the Sabouraud agar media?

The agar media contains three key ingredients: dextrose, peptones (pancreatic digest of casein), and peptic digest of animal tissues.

Dextrose is added as the energy and carbon source, and peptones are a subunit of casein which is a protein found in milk and is a high quality source of amino acids.  Peptic digests of animal tissues provide a nutritious source for the growth of fungi and yeasts.

The pH of the agar is adjusted to approximately 5.6 and it usually contains cycloheximide and chloramphenicol to prevent overgrowth of accompanying fungi and inhibit bacterial growth.

Download the Diagnosing Vesicular Ulcerative Conditions checklist to learn about diagnosing Histoplasmosis, Mucormycosis, and other conditions affection the oral cavity.

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Contraindications & Disadvantages

Before you start the procedure, here are a few things to keep in mind about the contraindications and disadvantages:

  1. It does not give information of which species are involved
  2. It does not provide quantitative information
  3. It may give false positive result

How to Perform an Agar Slant Culture Test

Prior to the procedure, introduce yourself to the patient, explain the purpose of the examination, obtain consent, and be sure to meet infectious control standards.

  1. Check expiration date of the Sabouraud Agar Slant
  2. Identify the area of suspected fungal infection
  3. Use a sterile cotton swab (Q-tip) and gently rub over the lesional tissue in attempt to collect the surface deposits
  4. Swab the Q-tip on to the agar for a couple of streaks
  5. Fasten the cap on slant tube, label it and keep it in an appropriate condition

Incubation

  1. Make sure the cap is fastened tight on the slant tube
  2. Put the tube in a test tube rack in a room with low/no light and a temperature of 25-37 °C
  3. After 2-7 days, examine the sample tube for fungal growth on the surface of the agar

Related Reading: A Dentist’s Guide: Oral Pathology of Vesicular Ulcerative Conditions

For Prosthesis

  1. Check expiration date of the Sabouraud Agar Slant
  2. Identify the area of suspected fungal infection
  3. Swab the first streak on the bottom-half of the agar slants with the oral sample
  4. Take a new Q-tip and moisturize it with water (sterile water is preferable)
  5. Rub the Q-tip against the prosthesis where it sits against the oral tissue
  6. Swab on to the top-half of the agar slants with prosthesis sample
  7. Indicate on the label on the tube which side is from oral tissue or prosthesis
  8. Fasten the cap on slant tube, label it and keep it an appropriate condition

Learn More:  USC’s Oral Pathology and Radiology Online Postgraduate Certificate Program

How to Interpret a Positive Result

A positive culture will show creamy white colonies. A negative or positive result must be read at the 2 to 3-day time point; the agar slant culture test is invalid beyond 3 days.  Keep the slant for at least two weeks before determining that the culture is negative.

Potential Causes of a Negative Result

  • There is no candida in the collected sample and the lesion is not due to fungal infection
  • The specimen was not collected properly
  • Antifungal treatment had been used prior to the collection of the specimen
  • The procedures were incorrect
  • The organism grew very slowly
  • Sample was taken from a hyperplastic candidiasis lesion

Download the Diagnosing Vesicular Ulcerative Conditions checklist to learn about diagnosing Histoplasmosis, Mucormycosis, and other conditions affection the oral cavity.

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