Indian Journal of Pathology and Microbiology
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Year : 2016  |  Volume : 59  |  Issue : 1  |  Page : 31-34
Kaleidoscope of oral artifacts: A vivid picture through light and polarizing microscope

1 Department of Oral Pathology and Microbiology, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India
2 Maharaja Ganga Singh Dental College and Research Centre, Ganganagar, Rajasthan, India
3 Department of Oral Pathology and Microbiology, ITS Dental College, Greater Noida, Uttar Pradesh, India

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Date of Web Publication9-Mar-2016


Background: This study is based on finding of an inexplicable artifact that was seen in the tissue received as periapical granuloma. Aim: To observe the histological appearance of different commonly implanted food particles and easily incorporated substances from a laboratory in the oral biopsy tissues. Materials and Methods: Various food particles such as wheat chapatti, beans, peas, pulses, and coriander leaves and substances such as a suture, cotton, and paper that can easily gain entry during biopsy and histotechnical procedures were intentionally introduced in the tissue specimens of a uterus from outside. Both light and polarizing microscopes were utilized to view them. Results: Different food particles and substances gave different appearances that could lead to misdiagnosis. Some of these also exhibited positive birefringence under the polarizing microscope. Conclusion: Knowledge and familiarity with probable foreign substances which can appear in tissues may help prevent misdiagnosis or erroneous diagnosis of biopsy specimens.

Keywords: Artifact, food materials, misdiagnosis, polarizing microscope

How to cite this article:
Kardam P, Jain K, Mehendiratta M, Mathias Y. Kaleidoscope of oral artifacts: A vivid picture through light and polarizing microscope. Indian J Pathol Microbiol 2016;59:31-4

How to cite this URL:
Kardam P, Jain K, Mehendiratta M, Mathias Y. Kaleidoscope of oral artifacts: A vivid picture through light and polarizing microscope. Indian J Pathol Microbiol [serial online] 2016 [cited 2021 Oct 18];59:31-4. Available from: https://www.ijpmonline.org/text.asp?2016/59/1/31/178218

   Introduction Top

Pathologists sometimes come across strange structures in the tissue sections that appear to be never seen by them and are unrelated to tissues. These might then be interpreted as artifacts and sometimes can lead to misdiagnosis or erroneous diagnosis. These substances may either be actually lying within the tissues or can get implanted into tissue during biopsy procedure or during laboratory handling, especially while grossing. This study is based on finding of an inexplicable artifact that was seen in the tissue received as periapical granuloma. Numerous well-defined, rectangular shaped structures, placed next to each other and with amphophillic outlines were observed [Figure 1]a. Attempts including thorough literature search, consultations with oral pathologists and uploading of the pictures on various pathology discussion forums were all futile. The opinions varied from some food material to insect wing, suture, etc.

The concept of food getting entrapped in the open carious cavities and reaching the apex is well-known. The food particles on entering the periapical area may induce granulation tissue formation, e.g., pulse granuloma (PG) or vegetable granuloma (VG). [1] Similarly, other materials or substances may get entrapped into oral tissues and may be diagnosed as an artifact or can lead to misdiagnosis. This study was a quest to find out the appearance of such abnormal structures in the tissue and to explore the various possible substances that can be seen in the oral biopsy tissues with their probable histological misdiagnosis.
Figure 1: Light microscopic appearance of artifact seen in periapical tissue and suture material. The photomicrograph shows (a) artefact seen in the periapical tissue received in our department which initiated this study (H and E, ×100); (b) suture material seen in longitudinal and cross sections (H and E, ×100)

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   Materials and methods Top

Various foreign materials that may reach the histopathologists via the biopsy tissue were included in this study. The study samples were divided into two groups; Group I consisted of food materials that may gain entry into the periapical region through wide open carious lesions and hence reach the histopathologist via biopsy tissue. These included food materials like wheat (Triticum) in the form of Indian bread, the seed of kidney bean (Phaseolus vulgaris), green pea (Pisum sativum), pulse (Phaseolus aureus), and coriander leaves (Coriandrum sativum). The second group (Group II) included foreign material that may be introduced during surgical removal (suture) or during grossing of tissue in the laboratory (cotton, paper, and nylon bristle). The study samples of both groups were intentionally introduced inside tissue of a uterus available in our laboratory. An incision using a scalpel and blade was made in the tissue and then the foreign material was pushed into the incision using a tissue forceps. Following the routine protocols of fixation, tissue processing and hematoxylin and eosin staining, the slides were microscopically evaluated by two observers. All the sections were also subjected to examination under polarizing microscope thereafter.

   Results Top

Light microscopy

The foreign materials of both groups gave varying appearances under light microscopic examination [Table 1].
Table 1: Light microscopic appearances and possible misdiagnoses of the foreign materials introduced into tissue

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Polarizing microscopy

The results for polarizing microscopy of both groups are tabulated in [Table 2] [Figure 2].
Figure 2: Polarising microscopic view of foreign materials. The photomicrograph shows polarising microscopic view of various foreign materials showing a positive birefringence; (a) paper (H and E, ×400), (b) suture (H and E, ×400); (c) cotton (H and E, ×400); (d) green pea (H and E, ×100), (e) kidney bean (H and E, ×100)

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Table 2: Polarising microscopy results of the different foreign materials introduced into tissues

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   Discussion Top

The word artifact in Latin literally means "ars" - art + "factum" - made. It signifies any artificial feature or structure accidentally introduced into the specimen that is under study. [2] An artifact under the eyes of a pathologist can lead to misdiagnosis that in turn may hamper appropriate treatment of the patient. There are only a handful of research papers that have discussed the importance of adequate recognition of artifacts. The studies that quote the probable causes of developing an artifact in biopsy specimens are even lesser. This study is unique because it presents the artifacts that may be created by food particles and hence is the first of its own kind.

There is ample data in the literature that enlightens us with the possible causes of artifacts encountered in microscopic evaluation of biopsy specimens. They can be incorporated during handling of tissues at the time of biopsy and during the histotechnical procedures of embedding and staining tissues. [3] The inexplicable artifact in the tissue received in our department as periapical granuloma that lead to the instigation of this study was evidently due to some foreign body/external agent incorporated from the environment. There was a possibility that the external agent might have reached the periapical tissue via the carious opening in the tooth.

The concept of food particles or foreign material being driven into the oral mucosa is known. Various authors have already suggested that particles of food may get implanted in the periapical region through extraction sockets, deep periodontal pockets, unfilled root canals and grossly decayed teeth. [4] Lewars in 1971 described six cases of foreign body reaction because of the intrusion of food particles into the mucosa of the mandible by a denture. [5] Nair in his study had quoted that various foreign bodies such as gutta-percha, food particles, endodontic paper and cotton wool, amalgams, endodontic sealants may reach the periapical region through the root canals. [6]

Entrapment of vegetable or plant material into periapical tissues is referred to as PG or VG. [1] Various exogenous and endogenous theories have been proposed regarding the pathogenesis of PG. The implantation of exogenous agents such as foreign/food material such as beans and peas in periapical tissues may elicit a reaction. The endogenous sources include degenerating collagen, vessel wall injury, coagulated serum proteins, and infectious agents like Torulopsis glabrata. [7] Histologically, they appear as homogenous eosinophilic material surrounded by acute and chronic inflammatory cells and foreign body giant cells. [8]

In this study, various foreign materials were introduced intentionally to create artifacts in the tissue to find the probable match for the unknown artifact received in the periapical tissue [Figure 1]a]. Out of all the substances, kidney bean and green pea matched the artifact closely [Figure 3]a and 3b. Under the polarizing microscope, the artifact in the periapical tissue as well as the artifacts which appeared due to kidney bean and green pea exhibited birefringent walls [Figure 2]. It has already been proven by various authors that the food materials that contain cellulose in their cell walls exhibit positive birefringence. [1],[8] Under the eyes of inexperienced pathologists, these artefacts can be misdiagnosed as connective tissue components like distorted or compressed adipocytes or collagen fibers [Figure 3]c and d.
Figure 3: Light microscopic appearance and possible misdiagnosis of kidney bean and green pea. The photomicrograph shows (a) kidney bean seen in longitudinal and cross sections (H and E, ×400); (b) fragments of green pea (H and E, ×100); (c) adipocytes seen in a lipoma (H and E, ×100); (d) collagen fibers (H and E, ×400)

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Among the food materials, wheat (in the form of Indian bread) can be easily misdiagnosed as a meshwork of fungal hyphae, e.g., Candida albicans. The histological appearance of the pulse was an interesting one, it closely resembled the calcifications which can be seen routinely in various pathologic lesions such as peripheral ossifying fibroma, cemento-ossifying fibroma, calcifying odontogenic cyst, etc., [Figure 4]a and 4b. The coriander leaves can be misdiagnosed as ghost cells as seen in lesions such as calcifying odontogenic cyst, dentinogenic ghost cell tumor, ameloblastoma, etc., [Figure 4]c and 4d]. It can sometimes even be misdiagnosed as eosinophilic tumor cell secretions as seen in cases of monomorphic adenoma, adenoid cystic carcinoma, and odontogenic tumors [Figure 4]e.
Figure 4: Light microscopic appearance and possible misdiagnosis of pulse and coriander. The photomicrograph shows (a) fragments of pulse (H and E, ×400); (b) calcifications seen in peripheral ossifying fibroma (H and E, ×400); (c) fragments of corriander (H and E, ×400); (d) ghost cells in calcifying odontogenic cyst (H and E, ×400); (e) tumor secretions seen in basal cell adenoma (H and E, ×400)

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Suture material when left inside the tissue during surgical procedures can present as numerous well defined polygonal isomorphous tiny structures. The majority of them may take up eosin stain whereas few may remain unstained giving a lumen-like appearance as formed by the folding of the thin stratified squamous epithelium. [9] However, in this study, suture material did not take up the stain and presented as isolated fragments cut in transverse, oblique or longitudinal planes [Figure 1]b]. Cotton and paper may get incorporated into tissues during grossing and laboratory handling. The paper may even reach the periapical tissue in the form of paper points used during the root canal procedure. Cotton in our sections resembled the eosinophillic exfoliated squames that can be inculcated in the tissue if the tissue is handled without gloves [Figure 5]a and 5b. Under the light microscope, paper material gave glassy pink linear/curvilinear/ring-shaped/angular appearance that may resemble rushton bodies as seen in odontogenic cysts [Figure 5]c and 5d]. Nylon bristles may get incorporated into the tissue from the brush used for handling the sections during microtomy. They resembled wheat under light microscopy and thus can be misdiagnosed as fungal hyphae or even a tissue showing thread like collagen fibers like myxoma [Figure 6]a, 6b, 6c and 6d].

Few studies have been carried out to evaluate foreign substances and vegetable matter present in oral tissues under polarizing microscopy. [1],[7],[8],[9],[10] In this study, kidney bean, green pea, suture, cotton, and paper appeared as birefringent particles whereas wheat, pulse, coriander leaves and nylon bristle did not show any birefringence. For vegetable matter (kidney bean and green pea), the surrounding cellulose membranes appeared light whereas the central starch content appeared dark. Suture material exhibited as multiple small strongly birefringent fragments. Cotton appeared as scattered irregular birefringent material whereas paper particles presented as closely placed curvilinear and angular structures with birefringent walls and central dark areas [Figure 2].
Figure 5: Light microscopic appearance and possible misdiagnosis of cotton and paper points. The photomicrograph shows (a) fragments of cotton (H and E, ×100); (b) squames of buccal mucosa (H and E, ×100); (c) fragments of paper points (H and E, ×400); (d) rushton body seen in epithelium of radicular cyst (H and E, ×400)

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Figure 6: Light microscopic appearance and possible misdiagnosis of nylon bristles and wheat. The photomicrograph shows (a) fragments of nylon bristles seen singly or in groups (H and E, ×400) (b) fragments of wheat (H and E, ×400); (c) fungal hyphae (Candida albicans) (H and E, ×400); (d) collagen fibers seen in myxoma (H and E, ×400)

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   Conclusion Top

Hence, as different materials get introduced and embedded into oral biopsy tissues, they may create diagnostic dilemmas to the pathologists. This study is an attempt to bring awareness of the histological appearance of these probable foreign substances in biopsy tissues. Further studies involving more variable and different materials can bring knowledge and familiarity of them and thus may help prevent misdiagnosis and erroneous diagnoses of biopsy specimens.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Manjunatha BS, Kumar GS, Raghunath V. Histochemical and polarization microscopic study of two cases of vegetable/pulse granuloma. Indian J Dent Res 2008;19:74-7.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
Jadhav KB, Gupta N, Ahmed MB. Maltese cross: Starch artifact in oral cytology, divulged through polarized microscopy. J Cytol 2010;27:40-1.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
Rastogi V, Puri N, Arora S, Kaur G, Yadav L, Sharma R. Artefacts: A diagnostic dilemma - A review. J Clin Diagn Res 2013;7:2408-13.  Back to cited text no. 3
Naik SV, Ghousia S, Shashibhushan K, Benni D. Pediatric oral pulse granuloma: A rare entity. Dent Res J (Isfahan) 2012;9:812-5.  Back to cited text no. 4
Lewars PH. Chronic periostitis in the mandible underneath artificial dentures. Br J Oral Surg 1971;8:264-9.  Back to cited text no. 5
Nair PN. On the causes of persistent apical periodontitis: A review. Int Endod J 2006;39:249-81.  Back to cited text no. 6
Sowmya SV, Patil S, Rao RS. Vegetable granuloma in Pindborg's tumor: A rare encounter. J Int Oral Health 2014;6:108-10.  Back to cited text no. 7
Kotrashetti VS, Angadi PV, Mane DR, Hallikerimath SR. Oral pulse granuloma associated with keratocystic odontogenic tumor: Report of a case and review on etiopathogenesis. Ann Maxillofac Surg 2011;1:83-6.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
Sonal G, Rashmi N, Jayadeva H, Ahmed Mujib B. Suture artefacts: Explored through polarising microscope. Sultan Qaboos Univ Med J 2012;12:247-8.  Back to cited text no. 9
Gouvêa AF, Hanemann JA, Pereira AA, Ribeiro AC, Romañach MJ, Jorge J, et al. Uncommon foreign body reactions occurring in the lip: Clinical misdiagnosis and the use of special techniques of analysis. Head Neck Pathol 2011;5:86-91.  Back to cited text no. 10

Correspondence Address:
Priyanka Kardam
D-81, Ground Floor, Saket, New Delhi - 110 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.178218

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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