• Users Online: 41
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2020  |  Volume : 15  |  Issue : 1  |  Page : 78-81

Comparison of the efficacy of cytodiagnostic instruments in exfoliative cytology

1 Department of Oral Pathology and Microbiology, Sharad Pawar Dental College and Hospital, DMIMS (Deemed to be University), Sawangi(Meghe), Wardha, Maharashtra, India
2 Department of Oral Medicine, Sharad Pawar Dental College and Hospital, DMIMS (Deemed to be University), Sawangi(Meghe), Wardha, Maharashtra, India

Date of Submission27-May-2020
Date of Decision16-Jul-2020
Date of Acceptance28-Jul-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Dr. Preethi Sharma
Assistant Professor, Department of Oral Pathology and Microbiology, Sharad Pawar Dental College and Hospital, DMIMS (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_205_20

Rights and Permissions

Aims and Objectives: The aims and objectives of the study were to determine the efficacy of wooden spatula, cytobrush, and toothbrush in obtaining cytology smears for early detection of oral premalignant lesions and also to compare the analysis of cytology smears with the histopathological diagnosis. The smears were observed and analyzed under a compound light microscope. Materials and Method: Fifty patients of clinically diagnosed oral leukoplakia patients attending the outpatient department of oral pathology and microbiology were considered for the study. The smear samples were obtained using wooden spatula, cytobrush, and toothbrush. The samples were manually analyzed in a double-blinded fashion. Histopathological diagnosis was confirmed using scalpel biopsy and a comparison was made between cytological and histopathological diagnosis. Statistical analysis was performed using Chi-square test. Results: In our study, toothbrush cytology was comparatively better (P < 0.05) than the cytobrush and wooden spatula in terms of analyzing uniformity of cells, adequacy of abnormal cells, and higher grades of dysplasia. Conclusions: Toothbrush biopsy is a relatively quick, easy, noninvasive, and effective tool for screening suspicious premalignant lesions as compared to the invasive, painful scalpel biopsy procedure which is often impractical. Early detection, diagnosis, and management of such lesions decrease the risk for malignant changes increasing the survival rates.

Keywords: Cytobrush, cytology, dysplasia, histopathology, leukoplakia, toothbrush

How to cite this article:
Sharma P, Chaudhary M, Kadao M, Patel S, Gawande M, Hande A. Comparison of the efficacy of cytodiagnostic instruments in exfoliative cytology. J Datta Meghe Inst Med Sci Univ 2020;15:78-81

How to cite this URL:
Sharma P, Chaudhary M, Kadao M, Patel S, Gawande M, Hande A. Comparison of the efficacy of cytodiagnostic instruments in exfoliative cytology. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Oct 28];15:78-81. Available from: http://www.journaldmims.com/text.asp?2020/15/1/78/297977

  Introduction Top

The most common cancer in the developing countries accounting for a major health problem is the oral cancer which has become the leading cause of death. In the Indian scenario, it accounts for almost 40% of all the cancers.[1] In spite of new treatment modalities, oral cancer has become a major concern, as the mortality rate has remained very high (more than 50%) for the past three and half decades. Over the past 50 years, the survival rate has been 5 years.[2] Early screening and detection of the white lesions and the suspicious lesions can prevent from further malignant changes and spread of the tumor, thus improving the survival rate and better quality of life of the patient.[3] Histopathological diagnosis of the tissue remains gold standard which is carried out after biopsy which is an invasive painful technique with psychological implications on patients.[4] Oral exfoliative cytology is a noninvasive, painless, rapid, cost-effective technique that can be performed for the early screening and diagnosis of the lesions. This method is easily accepted by the patients. The toothbrush method without the use of computer-assisted analysis is less expensive and may have a wider range of purposes in resource-challenged areas, thus contributing a reliable method of screening oral lesions.[5] The aim of the study is to assess the efficacy of cytodiagnostic instruments in terms of obtaining the quality of smear as well as the analysis of the smears under a microscope. The cytological diagnosis was also compared with that of histopathological diagnosis.

  Materials and Methods Top

The study was conducted in the Department of Oral Pathology and Microbiology, Sharad Pawar Dental College and Hospital, DMIMS, Sawangi (Meghe), Wardha. Institutional Ethical Committee clearance was obtained before performing the study. The patients were selected from the outpatient department of the department of oral pathology and microbiology. Clinically diagnosed 50 cases of potentially malignant disorders such as leukoplakia were included in the study. Detailed intraoral and extraoral examination along with general medical examination was carried out in all the patients. The entire procedure was explained to the patient and informed consent was obtained from the patients. Oral exfoliative cytology was performed using wooden spatula, cytobrush, and toothbrush in all the patients, followed by biopsy. The patients were asked to swish their oral cavity with water to clean off debris and the area of suspicion was cleaned with a swab and then smear was taken. A nylon baby toothbrush was sterilized for 24 h in 0.2% chlorhexidine gluconate mouthwash and was discarded after every use. The toothbrush was stroked in one direction repeatedly over the area of the lesion till the appearance of pinpoint reddish areas, thus attaining the epithelial cells through the entire epithelial thickness. The smear was spread on the dried glass slide, a fixative was sprayed, and staining was performed by the modified rapid Papanicolaou staining method (Bio Lab Diagnostics, India). The cells were observed under × 40 magnification using a compound light microscope. Overlapped, clumped, and folded cells were not taken into consideration for the analysis. The smears were analyzed for dysplastic features such as adequacy of abnormal cells, nuclear and cellular pleomorphism, hyperchromatism, and nuclear cytoplasmic ratio. The evaluation was done with respect to three different diagnostic criteria, i.e., Grade I – No abnormal or atypical cells, Grade II – Mild dysplasia, Grade III – Moderate dysplasia, and Grade IV – Severe dysplasia.

Ethical clearance

Ethical clearance was obtained from the Institutional Ethical Committee of SPDC, Sawangi (Meghe), Wardha, on 5th Dec 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/398.

  Results Top

Statistical analysis was performed using descriptive and inferential statistics using Chi-square test, and software used in the analysis was SPSS 24.0 version (Chicago, Illinois, USA) and GraphPad Prism 7.0 version (San Diego, CA), and P < 0.05 is considered as the level of significance. In the present study, out of 50 cases, 17 cases (34%) of leukoplakia affected the age group of 41–50 years, followed by 11 cases (22%) affecting the age group of 30–40 years [Graph 1]a. Oral leukoplakia was more common in males as compared to females [Graph 1]b. The most common site involved was the buccal mucosa (52%), followed by the alveolar mucosa (22%) [Graph 1]c. In the present study, 98% of oral lesional smears were graded as mild dysplasia [Graph 2] when the smear was obtained using a wooden spatula. Fifty-four percent of oral lesional smears were graded as mild dysplasia and 22% as moderate dysplasia when the smear was obtained by a cytobrush [Graph 3]. Fifty-eight percent of oral lesional smears were graded as mild dysplasia, 32% as moderate dysplasia, and 8% as severe dysplasia when the smear was taken by toothbrush [Graph 4]. All these findings were compared with histopathological diagnosis obtained after the biopsy. Sixty-four percent of the lesions were graded as mild dysplasia, 30% as moderate dysplasia, and 6% as severe dysplasia [Graph 5].

The proportion of oral potentially malignant disorders (OPMDs) in India is very high because of customs of different forms of tobacco chewing habits and areca nut consumption in comparison to western countries.[6] Dysplasia and carcinomas at initial stages mostly present with without symptoms and hence misdiagnosed or misinterpreted as benign lesions. The misleading perception of dental practitioners regarding such lesions at the time of discovery or the insignificant behavior of the lesion may be fundamentally responsible for the advanced stages, and hence, a complete cure is not possible.[7] The scalpel biopsy was followed by histopathological diagnosis, though considered as a gold standard, it is not always feasible to go with scalpel biopsy in all suspected cases. Most of the time, the patient may refuse to undergo scalpel biopsy or sometimes the patient may be medically compromised. In such situations, exfoliative cytology may offer an acceptable alternative method. In our study, we aimed to study the efficacy of cytodiagnostic instruments used such as wooden spatula, cytobrush, and toothbrush, and for this purpose, we also had to compare the cytological diagnosis obtained using these techniques with the histopathological diagnosis.

This study showed more preponderance for males with the largest number of leukoplakia developing in the fourth and fifth decades of life. These findings are similar to a study conducted by Gowhar et al. and Maia et al.[8],[9] This could be attributed to consumption of different forms of tobacco in higher proportion compared to females. In this study, the buccal mucosa was the most commonly involved site, followed by the alveolar mucosa (52% and 22%). These findings are similar to a study conducted by Mehrotra et al and Naga et al.[5],[10] When the smears were taken using wooden spatula, we could not obtain the smear from the deepest layers of the lesion. The cells obtained were inadequate, and only few overlapped and clumped cells were analyzed under a microscope. To overcome these factors, we also used cytobrush and baby toothbrush made of nylon for taking oral smears. The use of cytobrush also had certain disadvantages such as inadequate sampling and false-negative results. The use of nylon toothbrush improved the uniform spreading of cells on to the slides when compared with smears taken by using a wooden spatula and cytobrush, thus improving the smear quality.[11] The fact behind using the nylon toothbrush for obtaining smears is to take a preference of a first-level test that is useful in identifying abnormal cells or dysplastic cells which would be an implication for histopathological control, even in clinically diagnosed benign lesions of the oral cavity. A platform has been developed with the use of toothbrush between the visual clinical examination and referral for histopathological examination in screening of a patient. It helps to determine if an oral lesion with innocuous clinical features requires surgical biopsy during the time of oral examination. This procedure can be repeated a number of times for diagnosis, follow-up, and research purposes.[12] The sensitivity of the toothbrush was found to be 94%, whereas it was 60% for cytobrush and 40% for wooden spatula. The brush biopsy importance has been emphasized in a multicenter study for evaluating harmless-looking lesions where almost 5% of clinically appearing benign lesions of the mucosa were sampled and then diagnosed by scalpel biopsy to represent epithelial dysplastic changes or invasive carcinoma.[13] Several factors such as smear collection from the non representative area, improper fixation and staining of slides, improper analysis of the smear etc., are responsible for the errors and false negative results in the interpretation of cytology smears.[6]

In this study, a comparison was made between the cytological diagnosis and the histopathological diagnosis. It was found that the percentage of grading of dysplastic cells was almost equal to the percentage of grading of cells obtained using toothbrush.

  Conclusions Top

This study suggests that the use of nylon toothbrush in exfoliative cytology has the immense probability to fill the “Diagnostic Gap” that is presently challenging the early screening of OPMDs. It is a simple, noninvasive, painless, inexpensive method of detecting abnormal cells or dysplastic cells as well as early carcinoma in any setup and also in mass screening of patients in resource confronted countries such as India, which hold the major core of the disease constraint.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mehrotra R, Singh M, Kumar D, Pandey AN, Gupta RK, Sinha US. Age specific incidence rate and pathological spectrum of oral cancer in Allahabad. Indian J Med Sci 2003;57:400-4.  Back to cited text no. 1
[PUBMED]  [Full text]  
Pignon JP, Le Maître A, Maillard E, Bourhis J; MACH-NC Collaborative Group. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients. Radiother Oncol 2009;92:4-14.  Back to cited text no. 2
Macey R, Walsh T, Brocklehurst P, Kerr AR, Liu JL, Lingen MW, et al. Diagnostic tests for oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions. Cochrane Database Syst Rev 2015;2015:CD010276.  Back to cited text no. 3
Warnakulasuriya S. Histological grading of oral epithelial dysplasia: Revisited. J Pathol 2001;194:294-7.  Back to cited text no. 4
Mehrotra R, Singh MK, Pandya S, Singh M. The use of an oral brush biopsy without computer-assisted analysis in the evaluation of oral lesions: A study of 94 patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:246-53.  Back to cited text no. 5
Bhandari AP, Gadkari RU. Evaluation of role of cytodiagnostic techniques in detection of oral premalignant and malignant lesions: Study of 50 cases. Int J Oral Health Sci 2015;5:21-9.  Back to cited text no. 6
  [Full text]  
Guggenheimer J, Verbin RS, Johnson JT, Horkowitz CA, Myers EN. Factors delaying the diagnosis of oral and oropharyngeal carcinomas. Cancer 1989;64:932-5.  Back to cited text no. 7
Gowhar O, Ain TS, Singh NN, Sultan S. Prevalence of oral premalignant and malignant lesions in Moradabad, India: A retrospective study. Int J Contemp Med Res 2016;3:2079-81.  Back to cited text no. 8
Maia HC, Pinto NA, Pereira Jdos S, de Medeiros AM, da Silveira ÉJ, Miguel MC. Potentially malignant oral lesions: Clinicopathological correlations. Einstein (Sao Paulo) 2016;14:35-40.  Back to cited text no. 9
Naga SD, Gundamaraju KK, Bujunuru SR, Navakoti P, Kantheti LC, Poosarla C. Prevalence of oral potentially malignant and malignant lesions at a tertiary level hospital in Hyderabad, India. J NTR Univ Health Sci 2014;3:S13-6.  Back to cited text no. 10
Mehrotra R. The role of cytology in oral lesions: A review of recent improvements. Diagn Cytopathol 2012;40:73-83.  Back to cited text no. 11
Ramaesh T, Mendis BR, Ratnatunga N, Thattil RO. Diagnosis of oral premalignant and malignant lesions using cytomorphometry. Odontostomatol Trop 1999;22:23-8.  Back to cited text no. 12
Sciubba JJ. Improving detection of precancerous and cancerous oral lesions. Computer-assisted analysis of the oral brush biopsy. U.S. Collaborative OralCDx Study Group. J Am Dent Assoc 1999;130:1445-57.  Back to cited text no. 13


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...

 Article Access Statistics
    PDF Downloaded7    
    Comments [Add]    

Recommend this journal