The use of an oral brush biopsy without computer-assistedanalysis in the evaluation of oral lesions: a study of 94patientsRavi Mehrotra, MD, MIAC,a Mayank Kumar Singh, MD,b Shruti Pandya, MSc,b andMamta Singh, MD,a Allahabad, IndiaUNIVERSITY OF ALLAHABAD

Objective. The objective of this study was to evaluate the sensitivity and specificity of modified brush biopsy withoutcomputer-assisted analysis in the detection of oral premalignant and malignant lesions.Study design. Ninety-four patients attending outpatient clinics who exhibited oral lesions suspicious of premalignancyor malignancy were enrolled. All patients underwent an oral brush biopsy using a baby toothbrush followed by ascalpel biopsy. The specimens were analyzed manually in a double-blinded fashion. Sensitivity and specificity wereused for the statistical analysis of the samples. Statistical significance was determined using the normal approximationto the binomial distribution of matched results, approximated by the Student t distribution mean test (paired t test).Results. Seventy-nine patients with adequate transepithelial brush biopsy samples were included in the study group.When compared to scalpel biopsy, the statistical sensitivity of the brush biopsy was greater than 76.8% (P � .05)while the statistical specificity was greater than 93.3% (P � .05). There were 4 false negative brush biopsy cases. The4 false negative patients turned out to be dysplasia/ malignancy on histopathology. All 4 were patients with clinicaloral submucous fibrosis.Conclusion. The oral brush biopsy without computer-assisted analysis was found to be a painless, noninvasive test forevaluating oral lesions. The toothbrush brush biopsy with manual analysis had marginally lower sensitivity andspecificity than the commercially available oral brush biopsy with computer-assisted analysis. The results demonstratethat by using a toothbrush to obtain an oral brush biopsy sample, oral lesions can be easily evaluated in a resourcechallenged settings to rule out dysplasia and carcinoma. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;

106:246-53)

Oral cancer is a global health problem with increasingincidence and mortality rates; around 300,000 patientsare annually estimated to have oral cancer worldwide.1

The annual incidence of oral cancer in the United Statesis relatively low, affecting about 11/100,000 popula-tion, with a male/female ratio greater than 2:1, and thedisease is responsible for 2% of all cancer deaths.2,3

Recent data show that an estimated 29,370 new cases oforal cancer are expected to be diagnosed in UnitedStates this year and approximately 7320 people will dieof the disease. In India, on the other hand, oral cancerrepresents a major health problem constituting up to40% of all cancers and is the most prevalent cancer inmales and the third most prevalent in females.4,5

aProfessor, Department of Pathology, Moti Lal Nehru Medical Col-lege, University of Allahabad, Allahabad, India.bPostgraduate Student, Department of Pathology, Moti Lal NehruMedical College, University of Allahabad, Allahabad, India.Received for publication Jun 18, 2007; returned for revision Feb 22,2008; accepted for publication Feb 26, 2008.1079-2104/$ - see front matter© 2008 Mosby, Inc. All rights reserved.

doi:10.1016/j.tripleo.2008.02.030

246

Early detection has been the most effective approachto reduce morbidity and mortality from oral cancer.When encountering an oral lesion without an obviousetiology, options for the clinician include an observa-tion period of some defined time, toluidine blue stain-ing to assist in the selection of the most suspicious sitefor biopsy, various fluorescent or chemiluminescentaids to visualization of the lesion, oral brush biopsy toevaluate the lesion, or scalpel biopsy. There is sufficientevidence that visual inspection alone is not adequate todifferentiate precancers and early oral cancers frombenign lesions, regardless of the expertise of the clini-cian. Thus, oral lesions without an underlying etiologyshould not be observed or “watched” and instead, re-quire evaluation to rule out dysplasia and carcinoma.

Unlike cervical cytology, which has been shown tobe an accurate method of detecting dysplasia, the ex-amination of oral cytology specimens obtained bybrushing of the oral mucosa with a spatula or cytobrushresults in an unacceptably high number of errors.6 De-spite the fact that the histology is not without its dis-advantages, the most significant being the diagnosticvariability in the interpretation of dysplasia, which may

undermine the trust in histological assessment, it re-

OOOOEVolume 106, Number 2 Mehrotra et al. 247

mains the gold standard.7,8 A variety of ancillary tech-niques like toluidine blue, p53 analysis, AgNOR, andflow cytometry ploidy analysis have been investigatedin addition to oral brush biopsy and have yielded prom-ising results.9

The oral brush biopsy obtains a complete transepi-thelial biopsy specimen with cellular representationfrom each of the 3 layers (the superficial, intermediate,and parabasal/basal) of the lesion, thus providing acomplete disaggregated biopsy sample. The method ofobtaining cells from at least 2 layers of the epithelialtissue collected by any nonlacerational device such as abrush has been patented10,11 and developed as the oralbrush biopsy with computer-assisted analysis (Oral-CDx, Suffern, NY). The test is indicated for oral lesionsthat are not clinically suspicious, despite the fact thatsuch lesions may harbor dysplasia. Highly suspiciousoral lesions should still be subjected to an immediatescalpel biopsy to diagnose dysplasia and carcinoma.

The oral brush biopsy with computer-assisted anal-ysis has been found to be a simple, relatively inexpen-sive, highly sensitive, and specific test.12 The specimenis obtained by a specially designed brush and contrastswith an inadequate exfoliative cytology sample thatconsists only of cells from the superficial layer of theepithelium. The use of a brush biopsy without comput-er-assisted analysis may have applications in resourcechallenged areas and could be a risk-free method ofevaluating oral lesions. In this study, we determined thesensitivity and specificity of oral brush biopsy speci-mens obtained with a toothbrush and analyzed withoutcomputer-assisted analysis, while comparing the find-ings with a scalpel biopsy in the evaluation of oralpremalignant and malignant lesions.

MATERIAL AND METHODSNinety-four patients with suspicious oral lesions

from Departments of Otorhinolaryngology and Pathol-ogy, Moti Lal Nehru Medical College, Allahabad, In-dia, were studied in a random manner after obtainingclearance from the institutional ethical committee. Allpatients underwent an oral brush biopsy followed byscalpel biopsy and the results were compared in ablinded fashion. Permission was obtained by OralCDxto use a modified brush biopsy instrument, a babytoothbrush (Johnson & Johnson, Mumbai, India), inorder to obtain a transepithelial specimen. Suspiciouslesions tested included white or red patches. Only le-sions with an abnormal epithelial surface includingerythroplakia, leukoplakia without dysplasia and oralsubmucous fibrosis were included and submucosal le-sions including hemangiomas, mucoceles, papilloma,aphthous ulcers, melanoplakia, and fibromas were ex-

cluded.

Clinical data collectionPatients in generally good health with suspicious

lesions of the oral cavity, irrespective of site, stage andgender were selected. Detailed demographic informa-tion of each patient was obtained, including the pa-tient’s age, sex, occupation, dietary habits, dental hy-giene, personal habits, and present complaints.Emphasis was given to collecting information aboutconsumption of tobacco and alcohol. Detailed clinicalexamination was performed on each patient to assessthe site, size, and the clinical characteristics of thelesion as well as the extent of local infiltration (if any),cervical lymph node metastases (if any), and effective-ness of oral hygiene. Patients with medical problems ordental appliances, such as orthodontic or other fixedprostheses that could potentially interfere with the ex-amination were excluded. The study did not aim atmonitoring the patients in the long term.

Oral brush biopsy procedureAfter rinsing the oral cavity thoroughly with water,

the lesion was visualized under adequate illumination.A commercially available hard nylon baby tooth brush(Johnson & Johnson) was used to obtain a completetransepithelial biopsy with minimal discomfort. Usingmoderate pressure, the brush was repeatedly brushed inone direction over the entire lesion many times untilpinpoint bleeding was obtained, signaling entry intolamina propria and thus obtaining epithelial cellsthrough the full thickness of the epithelium. The mate-rial from the brush was spread on the middle third of 2clean, dried glass slides. The smears were fixed imme-diately with 100% ethanol for staining with hematox-ylin and eosin and the modified Papanicolaou’smethod. As the cellularity from this type of brushbiopsy sample is scant, only slides with at least 30well-preserved cells (i.e., not obscured by blood orexudate or necrosis) from deep epithelial layers (inter-mediate or parabasal-basal), were considered adequate.The minimum number of cells confirmed to the ade-quacy criteria previously followed by Navone et al.13

Inadequate specimens were excluded from the data.All specimens were examined manually indepen-

dently by 2 different cytopathologists in a double blindfashion. If there were any discrepancies, a third opinionwas obtained to reach a final diagnosis. As the cyto-logical slides were evaluated by cytopathologists andthe patients were examined by the ENT or dental spe-cialists, there was no chance of bias. The followingparameters were analyzed in the smears: enlarged nu-clei, variation in nuclear size and shape (pleomor-phism), nuclear borders, nucleo:cytoplasmic ratio,number of nuclei, binucleation, keratinization (Fig. 1),

tadpole forms, and hyperchromatism (Fig. 2) chromatin

OOOOE248 Mehrotra et al. August 2008

pattern and distribution as well as discrepancy in nu-cleo-cytoplasmic maturation. Cells showing clear-cutevidence of these changes, especially if present in thebackground of tumor diathesis, as evidenced by necro-sis and dysplastic changes were categorized as malig-nant. Those exhibiting borderline changes were consid-ered dysplastic while those with no specific changeswere labeled benign. For purposes of analysis, dysplas-tic and malignant lesions were considered positive andbenign lesions were considered negative.

HistopathologyFor histological diagnosis (after routine processing

and paraffin embedding), several sections (3- to 4-�mthickness) were cut from each case and stained withhematoxylin and eosin. All specimens were examinedmanually, independently by 2 different pathologists in adouble-blind fashion. If there were any discrepancies, athird opinion was obtained to reach a final diagnosis.Dysplasia, as evidenced by lack of orientation andpleomorphism of size and shape were considered, asdescribed elsewhere.14 The World Health Organization(WHO) classification dividing squamous cell carci-noma into well, moderate, and poorly differentiatedcases or grades I to III accordingly was used to in thehistopathologic evaluation. Grade I usually exhibitsintercellular adhesions.

Statistical analysisSensitivity and specificity were used for the statisti-

cal analysis of the samples. The true and false positivesand negatives were based on the following:

● True positive: Samples that were positive on both

Fig. 1. Microphotograph of an oral brush smear showing anatypical squamous epithelial cell with evidence of intracellu-lar keratinization and binucleation in a patient of oral submu-cous fibrosis with dysplasia (modified PAP �1000).

histology and brush biopsy.

● True negative: Samples that were negative on bothhistology and brush biopsy.

● False positive: Samples that were negative on histol-ogy and positive on brush biopsy.

● False negative: Samples that were positive on histol-ogy and negative on brush biopsy.

Statistical significance was determined using the nor-mal approximation to the binomial distribution ofmatched results, approximated by the Student-t distri-bution mean test (paired t test).

RESULTSOf the 94 brush biopsy samples, 15 (15%) were

considered inadequate and were excluded from the dataanalysis. Of the 79 adequate cases, 60 (76%) weremales and 19 (24%) were females (M:F � 3:1). Theage of patients ranged from 10 to 80 years with themajority of patients being in the 40 to 70 years agegroup. Among various substances of abuse, tobaccoconsumption was the most common with 43 patients(54%) having used it in one from or another. Twenty-eight patients (35.4%) gave a history of exposure tomore than one carcinogen while 4 patients (5%) con-sumed heavy amounts of alcohol. No attempt was madeto correlate the demographic details with the patholog-ical diagnosis.

On histopathology, 45 patients (53.6%) had benignlesions including erythroplakia, leukoplakia withoutdysplasia, and oral submucous fibrosis; 11 patients(13.1%) had dysplasia; and 28 patients (33.3%) hadsquamous cell carcinoma. Of the 28 malignant cases,

Fig. 2. Microphotograph of a positive oral brush smear show-ing tadpole cells with hyperchromatic nucleus and long cy-toplasmic tail in oral malignancy (modified PAP �1000).

19 (67.8%) were well differentiated, 8 (28.5%) moder-

OOOOEVolume 106, Number 2 Mehrotra et al. 249

ately differentiated and 1 (3.5%) was a poorly differ-entiated carcinoma.

Among cases diagnosed by scalpel biopsy as squa-mous cell carcinoma, the most common sites werebuccal mucosa 10 (35.7%) and tongue 6 (21.4%), fol-lowed by lip 5 (17.8%) and alveolus 4 (14.3%). This isdepicted in Fig. 3. Oral hygiene in general, assessedduring the clinical examination, was poor in all pa-tients.

The statistical sensitivity of the brush biopsy, definedas a measure of the likelihood that a patient withdysplasia or carcinoma will have an abnormal brushbiopsy result, was 76.8% (P � .05). Forty-two of the 46histologically confirmed benign lesions were negativeon brush biopsy while the 4 false negative patientsturned out to be dysplasia/malignancy on histopathol-ogy (Table I). All these 4 were clinically patients withoral submucous fibrosis. The statistical specificity ofthe oral brush biopsy, defined as a measure of thelikelihood that a patient with a benign lesion will havea negative brush biopsy result was 93.3% (P � .05).

Subject acceptability of the brush biopsy procedurewas evaluated by inquiring about pain and discomfort(unpleasant feeling other than pain). Nearly two thirdsof the subjects reported no discomfort, one third expe-rienced very mild discomfort, and 4 had moderatediscomfort. None of the patient reported significantpain.

DISCUSSIONThe subtle clinical features of precancer and early

oral cancers hinder their recognition. These limitationscannot be overcome even in institutions with extensiveteaching programs, including the distribution of a pic-torial manual and a series of lectures/diagnostic ses-sions aimed at training and calibrating clinical exami-nations of the oral cavity.5 There is no doubt that the

10

4

0123

456789

10

Buccalmucosa

Alveolus

No of patients

Fig. 3. Depicting the sites of involvement.

use of histology on conventional scalpel biopsy speci-

mens is only a subjective method with a low reproduc-ibility which does not suffice for the sampling of mul-tiple lesions and has a limited prognostic value.7,8 It isunlikely that a single cancer cell diagnosis15 usingmonocellular measurements of markers and morphol-ogy obtained by complicated and expensive technolo-gies could become practical.

Dysplasia and early carcinomas are asymptomaticand commonly misinterpreted as benign lesions or in-nocuous oral problems. The inconspicuous nature ofthese lesions or misleading perception of practitionersmay primarily be responsible for the advanced stages ofthese tumors at the time of discovery.16 A reasonableapproach might well be to combine ancillary methodswith cytology (liquid-based morphology, ploidy of theDNA), noninvasive microbiopsies, AgNOR (for diag-nosis and prognosis), immunocytochemistry, molecularbiology, and so forth.17

Epidemiological and clinical aspectsThis study revealed a male:female ratio of 3:1 with the

largest number of oral cancers developing in the fourthand fifth decades of life. This is consistent with an earlierreport from this group that confirmed that oral cancer inNorthern India was a disease of middle-aged men.4

In this study, the buccal mucosa and tongue were the

5

12

2/3e

Lowerlip Palate Floor ofmouth

Site

Table I. Evaluation of brush biopsy versus histopa-thology (n � 79)

Scalpel biopsydysplastic or

malignant

Scalpelbiopsybenign Total

Brush biopsy positive 30 3 33Brush biopsy negative 4 42 46Total 34 45 79

6

Anteriortongu

most frequently involved sites (35.7% and 21.4% re-

OOOOE250 Mehrotra et al. August 2008

spectively), while the palate was the least commonlyinvolved site (3.5%). In contrast, the lateral tongue andfloor of mouth are the more commonly involved sites inthe West. The anterior two thirds of the tongue iscommonly involved in India; while the posterior lateralborder and ventral surfaces are frequently involved inthe United States.18 These regional differences may beattributed to the extensive use of chewing tobacco inthe Indian subcontinent compared to smoking in theWest with the incidence being highest at mucosal siteswith prolonged contact with carcinogens.19 Consump-tion of alcohol is also lower in the Indian population ascompared to tobacco consumption.

Exfoliative cytologyThe current general perception is that the sensitivity

of exfoliative cytology is not sufficient to warrant itswidespread use as a screening modality to triage visiblelesions. Oral cells can be obtained by different physicalsystems of scraping the surface of the mucosa, byrinsing the oral cavity or even by taking a sample ofsaliva from the patients. The use of oral cytology forlarge, advanced and obviously malignant lesions is oflimited use. Unlike the cervical Papanicolaou smear,which has become an established adjunct in clinicalpractice and significantly impacted the mortality fromcervical cancer, exfoliative cytology in the oral cavityhas proven to be a little value because of high falsenegative rates, which can exceed 30%.20 The poorresults are due, in part to the fact that cytology instru-ments do not obtain a sample from the deepest layers ofthe oral lesion.

It is well established that only 20% of cervical cy-tology cells collected on a variety of collection devicesfrom the uterine cervix can be mechanically transferredto the flat surface of a glass slide and the small portionof cells that do get onto slide are not randomly selectedfrom the sampling device.21 It is suggested that a po-tential source for false-negative smears may be the lownumber of the cells that are transferred on to the glassslide. To a lesser degree, oral cytology also suffers fromthis deficiency.22

Oral brush biopsyThe commercially available computer assisted oral

brush biopsy system, OralCDx, is a diagnostic proce-dure with high sensitivity and low false negative valuefor detection of dysplasia and innocuous-appearing oralcancers at an early, curable stage. Sciubba demon-strated a high sensitivity of 96% with a false negativerate of up to 4% by using this technique.12 In all studieswhere brush biopsies and scalpel biopsies were per-

formed concomitantly on the same lesion and by the

same examiner, the results of the US pivotal clinicaltrial were replicated.23

The oral brush biopsy has broad potential to fill the“Diagnostic Gap” that currently challenges the earlydetection of oral cancer and can be an effective andnoninvasive means of detecting dysplasia as well asearly carcinoma in those patients who are either asymp-tomatic or in those with minor symptoms who do notwarrant immediate biopsy. Ahmed et al.,24 in theirstudy, reported that the mean delay time in diagnosinga carcinoma in different cases was 117.25 days becauseharmful lesions that were benign-appearing were notevaluated promptly. Scheifele et al.23 suggested that themain reason for the use of oral brush biopsy is not tofind a substitute for scalpel biopsy, but rather to takeadvantage of a first-level test that is able to identifydysplastic cells or molecular alterations which wouldbe an indication for histological control, even in clini-cally apparently benign oral lesions.

The oral brush biopsy has developed a bridge be-tween the visual examination and referral for histologicevaluation in the clinical assessment of a patient. Ithelps to determine if an oral lesion with innocuousclinical features requires surgical biopsy during thetime of oral examination. The improved accuracy ofthis technique over cytology is attributed to the com-plete transepithelial cellular sample and the analysis ofspecimens with computer assistance.

The importance of the brush biopsy for evaluatingharmless looking lesions has been emphasized in amulticenter study where nearly 5% of clinically benign-appearing mucosal lesions were sampled and later con-firmed by scalpel biopsy to represent dysplastic epithe-lial changes or invasive cancer.12,25 However, cytologyhas its limitations in not being able grade dysplasia andinitial attempts by the authors failed and were thusabandoned in this study. The value of the brush biopsyto diagnose oral candidiasis and epithelial infectionsdue to Epstein-Barr virus in oral lesions of hairy leu-koplakia, has widened its applications in the evaluationof oral lesions.26

Of course, the number of cells examined in this study(minimum 30 well-preserved cells) was significantlyless than hundreds of thousands of cells on a typicalOralCDx slide that is subsequently examined by thecomputer. In this study, there was a 15% inadequatesample rate, a number that is greater than twice thatreported for the commercial OralCDx brush biopsy.However, unlike the OralCDx brush, which was spe-cifically designed to penetrate down to the basementmembrane, we used an inexpensive baby toothbrush.

Although the brush biopsy is indicated to evaluateoral lesions that are not suspicious to warrant a scalpel

biopsy, some may argue that this study included lesions

OOOOEVolume 106, Number 2 Mehrotra et al. 251

that were highly suspicious as evidenced by the factthat 46% of lesions proved to be dysplastic or cancer-ous. However every single patient with an epitheliallesion was subjected to both scalpel biopsy and histol-ogy and thus, there was absolutely no selection bias.This could reflect the high prevalence of oral prema-lignant and malignant conditions in the populationscreened. Furthermore, the results were evaluated in adouble-blinded fashion.

In the 2 studies where brush biopsies and scalpelbiopsies were performed concomitantly on the samelesion and by the same examiner, the sensitivity ofOralCDx was shown to be greater than 92%.12,23 Theimproved accuracy compared to the present results maybe because the specimens were obtained with a spe-cially designed brush that penetrates to the basementmembrane, and the specimens analyzed with computerassistance. A computer specially designed to detectoptical and suboptical changes unique to abnormal oralepithelium identifies suspicious cells for a pathologistto evaluate.12 This highly specialized neural network-based image-processing system specifically can detectas few as one or two abnormal individual cells amongthe several hundred thousand normal cells typicallyfound on an OralCDx brush biopsy specimen.27

The brush biopsy with computer-assisted analysishas been shown to have a high positive predictive valueof 30% to 38% (exceeding the Pap smear and mam-mography) and leads to earlier cancer diagnosis.28-30

Because of its less invasive nature, health care provid-ers are more likely to use the brush biopsy on lesionsthat they would have not have otherwise been subjectedfor immediate biopsy, and therefore, detect dysplasiaand early carcinoma among lesions that would other-wise not have been promptly evaluated. How ever, itmust be stated that this study included frankly malig-nant appearing lesions. This could bias this study to-ward a higher sensitivity than the original Oral CDxstudy, which included lesions that had a more ”innoc-uous” appearance.

In the study, 4 false negative cases were reported.Discrepancy between the brush biopsy and scalpel bi-opsy may be due to sampling different sites of the samelesion. As others have reported, dysplasia is not uni-formly present in a lesion and, in most cases, a generaldentist or pathologist performs the brush biopsy whilea surgeon performs the scalpel biopsy procedure. Dif-ferences between brush biopsy and histopathology mayalso arise as a result of error in the interpretation of thehistological sample. Furthermore, there is significantinterobserver and intraobserver variability in the histo-logic assessment of oral premalignant lesions.31

Most investigators advocate the use of toluidine blue

as an adjunct to clinical judgment, which may acceler-

ate the decision to perform a biopsy and assist in theselection of the most suspicious site. One commonlyexpressed concern over the value of toluidine bluestaining is the fairly high incidence of false positives inlesions due to trauma or inflammation. However, byemploying a protocol to restain suspicious areas in 2weeks’ time may reduce the number of false positivesto fewer than 10%.32

Combining toluidine blue staining and brush biopsyhas been previously attempted by the authors’ team forearly detection of oral cancer. This combination wasfound to be highly sensitive (89%) and moderatelyspecific for malignant lesions but less sensitive for thepremalignant lesions.33

Liquid-based cytologyLiquid-based cytology (LBC) offers significant ad-

vantages over conventional exfoliative cytology. Themethod may also have applications for research andpractice in the field of oral cancer.34 In cervical cancerscreening, the liquid-based preparations have also dem-onstrated a significant reduction in false-negative ratesas compared with conventional smears.35-37 As cervicalcytology by this method becomes more wide spreadand cost of technology decreases, its use may becomemore widespread. A recent study has shown the liquid-based preparations resulted in higher specimen resolu-tion as well as better cytological morphology for pem-phigus vulgaris, squamous cell carcinomas, HSVlesions, and fungal infections. For HSV lesions, inparticular, the observation of the cytopathologic fea-tures indicative of viral infections (binucleated andmultinucleated cells) greatly improved with the liquid-based technique.38 Advances in the development ofautomated cytomorphometric methods combined withgenetic and proteomic profiling may provide the re-quired tools to refine screening strategies in the fu-ture.34,39 Kujan et al.34 recently showed that immuno-cytochemical staining of oral cells based on LBC slidesis also feasible. All the stained slides in their study wereconsistent and presented high-quality immunoreactivityfor FHIT. Likewise, Human papillomavirus (HPV) de-tection in oral LBC samples was also found to bereliable. Navone et al.13 also recently reported bettersensitivity and specificity in liquid based than in con-ventional cytology and there were fewer inadequatesamples (8.8% versus 12.4%). Moreover, having manymore cells on the glass slide is a significant advantageof LBC technique. It also eliminates many obscurantsseen in either the OralCDx brush biopsy or the presentstudy. On the other hand, an oral brush biopsy yields afull-thickness epithelial specimen often with microbi-opsy fragments and not a collection of spontaneously

exfoliated superficial cells that are obtained by a cer-

OOOOE252 Mehrotra et al. August 2008

vical Pap smear. Since the LBC system filters thespecimen into a thin monolayer, it may potentiallydestroy the 3-dimensional architecture provided by themicrobiopsies in an oral brush biopsy specimen.

CONCLUSIONThis study suggests that early detection of oral car-

cinoma is possible even at the precancerous stages byusing noninvasive, painless outpatient-based proce-dures like a toothbrush oral brush biopsy. This tech-nique showed a reasonable specificity and sensitivitythat makes it a potentially practical tool in resourcechallenged settings like rural India, which bear thebrunt of the disease burden. Although the accuracy ofthis modified brush biopsy is less than that reported forthe commercial brush biopsy with computer-assistedanalysis, it is simple, rapid, noninvasive, and well ac-cepted by patients that may be used in the evaluation oflesions that would not ordinarily be subjected to scalpelbiopsy.

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Reprint requests:

Dr. Ravi Mehrotra MD, MIACProfessor, Department of PathologyM.L.N. Medical CollegeUniversity of AllahabadAllahabad, India

rm8509@gmail.com