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ORIGINAL ARTICLE
Year : 2021 | Volume
: 24
| Issue : 3 | Page : 355-361
Prevalence of odontogenic cysts and tumors on turkish sample according to latest classification of world health organization: A 10-year retrospective study
E Izgi, N Mollaoglu, MB Simsek
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gazi University, Emek-Ankara, Turkey
Correspondence Address:
Dr. E Izgi
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gazi University, Ankara
Turkey
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/njcp.njcp_175_20
Abstract
Aim: The aims of this study are to investigate the prevalence of odontogenic cysts and tumors occurred in a sample of Turkish population in the last 10 years and to compare the data with latest reports. Methods and Material: The present retrospective study was carried out at Gazi University, School of Dentistry (GUSD) in Ankara, Turkey. All the data was retrieved from the GUSD archive on patients treated for various oral and maxillofacial lesions between 2008 and 2018. Patients' demographical data, main clinical features of the lesions along with histopathological findings were retrieved from the dental files of the patients. The type of lesions was evaluated according to the latest Head and Neck Tumor (HNT) classification published by the World Health Organization (WHO) in 2017. Data was analyzed by descriptive statistics and Chi-square test using SPSS version 21.0 software. Results: Among a total of 739 biopsy-conducted lesions, 467 (63.19%) were odontogenic cysts, 43 (5.82%) were benign odontogenic tumors, and 7 (0.95%) were malignant tumors. The rest of 222 cases were defined as others. Conclusions: The present study assessed the demographic and clinico-pathological characteristics of odontogenic cysts/tumors in a group of Turkish people, who visited GUSD for therapeutic purpose in the past 10 years. Results showed that male patients in their 5th-6th decades have the highest risk of odontogenic cyst/tumor, especially in the mandibular posterior region.
Keywords: Odontogenic cysts, odontogenic tumors, oral lesions, prevalence
Introduction 
Oral and maxillofacial lesions have a wide spectrum of clinical and histopathologic features from benign to malignant lesions that require different treatment approaches. These lesions have a great significance concerning their direct influence on patients' facial aesthetics and oral function; therefore, early diagnosis of these disorders may prevent possible inappropriate interventions. Understanding the clinicopathologic features of these lesions has a critical role in early diagnosis and accurate management. These clinical parameters may vary according to geographic areas and ethnicities.[1]
In January 2017, the 4th edition of the World Health Organization (WHO) classification of Head and Neck Tumors (HNT) was published.[2] In the latest classification system, odontogenic cysts and odontogenic tumors were reclassified and some new entities were added; making significant changes on the 3rd edition published in 2005.[3] As in previous editions, the 4th edition of the WHO HNT classification also divided odontogenic tumors into two categories based on their biological character as malignant and benign. The 4th edition also has a simpler categorization of benign odontogenic tumors such as epithelial, mesenchymal (ectomesenchymal), and mixed odontogenic tumors while the previous classification had a more complex categorization with the following three subgroups: (1) Odontogenic epithelium with mature fibrous stroma without odontogenic ectomesenchyme, (2) Odontogenic epithelium with odontogenic ectomesenchyme with or without hard tissue formation, and (3) Mesenchyme and/or odontogenic ectomesenchyme with or without odontogenic epithelium.[4] Malignant odontogenic tumor classification was also simplified and clarified in the 4th edition.
Moreover, there were some changes in odontogenic cysts classification when compared to the previous one. Latest WHO HNT classification rearranged the terms of odontogenic keratocyst and calcifying odontogenic cyst. While they were classified as tumors in the previous WHO classification, the latest one included both entities as cysts. In addition, a new entities described as sclerosing odontogenic carcinoma and primordial odontogenic tumor were also added to the 4th edition. Furthermore, some of the lesions including ameloblastic fibrodentinoma, ameloblastic fibroodontoma, and odontoameloblastoma which were previously defined poorly were excluded from the latest classification. Terminology of “Cemento” was also added to the new classification to emphasize that cemento-ossifying fibroma and cemento-osseous dysplasias have odontogenic origin. [Table 1] displays the current odontogenic tumors and cysts classification.[2] This study aims to investigate the prevalence of odontogenic cysts and tumors occurred in a sample of Turkish population in the last 10 years and to compare the results with other studies from different geographical regions of the world.
Table 1: Classification of odontogenic tumors and jaw cysts according to the edition of WHO published in 2017[2] Materials and Methods A retrospective study was carried out among individual attended to GUSD, Department of Oral and Maxillofacial Surgery in Ankara, Turkey. Data of patients diagnosed with oral and maxillofacial lesions between 2008 and 2018 were analyzed retrospectively. Demographic data, clinical features, and histopathological findings of the patients were retrieved from dental files. Ages and genders of the patients and the location of each lesion were noted. All case records were re-evaluated to classify according to the latest criteria of the WHO published in 2017.
A total of 4 locations were determined: anterior maxillary area, posterior maxillary area, anterior mandibular area, and posterior mandibular area. Anterior region was considered from right canine to left canine in maxilla and mandible; while posterior region was considered as the area between first premolar and third molar, regardless of the side.
Statistical analysis
Statistical analyses were performed with IBM SPSS for Windows Version 21.0 package program (IBM Corp released in 2012, SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Numerical variables were summarized with mean ± standard deviation. Categorical variables were given in numbers and percentages. Differences in categorical variables among independent groups were investigated with Chi-Square test. The significance level was set as P < 0.05.
Ethical approval
This study was approved by Gazi University, School of Dentistry, Clinical Research Ethics Committee (Decision number: GUDHKAEK.19.05/1).
Results This retrospective study included a total of 739 records of patients treated for oral and maxillofacial lesions between 2008 and 2018. Four hundred and twenty seven (57.8%) of these patients were male and 312 (42.2%) were female. The mean age was 39,3 ± 16,1 (4-84) years. Four hundred and sixty seven (63.19%) of the lesions were odontogenic cysts, 43 (5.82%) were benign odontogenic tumors and 7 (0.95%) were malignant tumors when reclassified according to the latest WHO classification. The remaining 222 (30.04%) lesions were defined as “Others.”
I. Odontogenic cysts
The most common types of odontogenic cysts were radicular cysts (n: 230, 49.25%), dentigerous cysts (n: 106, 22.7%), odontogenic keratocysts (n: 64, 13.7%), and inflammatory collateral cysts (n: 36, 7.71%), respectively. These cyst types constituted 93.36% of all odontogenic cysts. The male to female ratio was found as 1.38:1 (271 male and 196 female patients) [Figure 1].
Figure 1: Frequency of odontogenic cyst according to gender variation (n). Graphic in figure was obtained by using 2016 version of Microsoft Excel programMost of the odontogenic cysts were detected in patients in their 5th decade constituting 21.84% of all cases, followed by those in 4th decade with 20.34% of cases and the cases were the least in the 1st decade with a rate of 1.93%. There was no significant difference among all decades (P > 0.05).
A total of 165 odontogenic cysts (35.33%) were located in the maxilla while 302 lesions (64.67%) were located in the mandible. More than half of the lesions (52.89%) were found in the posterior mandibular area. Anterior maxillary area (24.41%) was the second most common site. A statistically significant relationship was found among four anatomic sites (P < 0.001) [Table 2].
Table 2: Distribution of odontogenic cysts and benign odontogenic tumors according to the anatomic sitesRadicular cysts represented 49.25% (n:230) of all odontogenic cysts and they were more frequent in males. Incidence of radicular cysts peaked in the 5th decade of life, however there was no statistically significant difference between age and radicular cyst presence (P > 0.05). The most common site of radicular cysts was posterior mandibular area and anterior maxillary area was the second. There was a statistically significant relationship in the location of radicular cysts (P < 0.05) [Table 2]. On the other hand, 106 cases of dentigerous cyst and 64 cases of odontogenic keratocysts were reported, representing 22.7% and 13.7% of all odontogenic cysts, respectively. Likewise, dentigerous cysts (73.58%) and odontogenic keratocysts (67.19%) were more frequent in posterior mandibular area (P < 0.05) [Table 2]. The incidence of dentigerous cysts peaked in the 4th-5th decade while odotogenic keratocysts were most common in 5th decade (P > 0.05). Both were mostly seen in male populations.
II. Odontogenic tumors
Forty three benign odontogenic tumors were detected after histopathologic evaluation according to 2017 WHO classification. The most common types of benign odontogenic tumors were odontoma (n:28, 65.12%) and followed by ameloblastoma (n:5, 11.63%). They constituted 76.75% of all benign odontogenic tumors. The overall male-to-female ratio was 1.39:1 (25 males and 18 females) [Figure 2]. The 6th decade was the most prevalent one (n:12, 27.91%) followed by the 2nd decade (n:8, 18.6%).
Figure 2: Frequency of benign odontogenic tumors according to gender variation (n). Graphic in figure was obtained by using 2016 version of Microsoft Excel programBenign odontogenic tumors (n:43) were mostly localized in mandible (n:31, 72.09%), especially in posterior area (n:17, 39.53%) [Table 2]. There was a statistically significant difference among four anatomic sites (P < 0.001).
Odontoma presented 65.12% (n:28) of all benign odontogenic tumors. More than half of them (n = 18; 64.29%) were found in males. The 6th decade was the most prevalent age group and the most frequent location was anterior mandibular area. Ameloblastoma which was the 2nd most common benign odontogenic tumor was reported in 5 patients. Except one case, the rest four of them were located in the posterior mandibular area and three out of five cases were male patients [Figure 2].
In addition, 7 malignant tumors were detected and none of them had an odontogenic origin. Five of them were primary intraosseous squamous cell carcinoma, 1 was metastatic adenocarcinoma, and 1 was mucoepidermoid carcinoma. The overall male to female ratio was 2.5:1. The 5th decade of life was found to be the highest risk group in terms of malignant tumors (n:3, 42.8%). Two (28.6%) of them were in the 6th decade. The malignities were mostly in the anterior maxilla (n:3, 42.8%), followed by equal amounts of maxillar (n:2, 28.6%) and mandibular posterior region (n: 2, 28.6%).
III. Others
The rest of the 222 cases were defined as others: periapical lesions (periapical granuloma and periapical cemental dysplasia) (n:116, 52.25%), giant cell lesions and bone cyst of jaw (n:29, 13.06%), maxillofacial fibro-osseous lesions (n:18, 8.11%), dental follicle (n:14, 6.31%), maxillary sinus pathology (n:11, 4.95%), reactive soft tissue enlargements (pyogenic granuloma) (n:10, 4.5%), osteomyelitis (n:8, 3.6%), minor salivary gland pathology (n:6, 2.7%), osteonecrosis of the jaw (n:5, 2.25%), bone tumors of the maxillofacial region (n:4, 1.8%), benign soft tissue tumors of the oral cavity (traumatic fibroma) (n:1, 0.45%).
Discussion The 4th edition of the WHO Classification of HNT was published in January 2017.[2] The updated classification has some important differences including a new classification for odontogenic cysts, reclassification of odontogenic tumors, and some new entities when compared to the 3rd edition.[5] This paper aims to present the latest relative frequency, clinical, and demographical characteristics of odontogenic cysts and tumors detected in GUSD between 2008 and 2018 according to the latest WHO edition.
In this study, odontogenic cysts were identified in 467 out of 739 specimens (63.19%). When the search results of the present study were compared to the results of other studies from Mexico,[6] Italy,[7],[8] India,[9] Kenya,[10] Brazil,[11],[12],[13] Australia,[14] Greece,[15] and Iran,[16] it was found that the studies from Brazil[12] and Kenya[10] reported a similar frequency for odontogenic cysts. Nevertheless, the studies from Mexico,[6] India,[9] Brazil,[11],[13] Greece,[15] and Iran[16] reported lower frequencies ranging between 6.8% and 17.66% for odontogenic cysts [Table 3]. The most common types of odontogenic cysts in this study were radicular cysts (49.25%), dentigerous cysts (22.7%), and odontogenic keratocysts (13.7%), respectively. They constituted 85.65% of all odontogenic cysts presenting a close similarity with various studies [Table 2].[5],[6],[7],[8],[11],[12],[13],[14],[15],[16] However, Butt et al. reported that dentigerous cysts (31%) were the most common type of odontogenic cysts, followed by radicular cysts (22%) in Kenya[10] with a small differences. Similarly, Baghaei et al. identified dentigerous cyst (27.2%) as the most common odontogenic cyst and radicular cyst (18.6%) as the 2nd in Iran.[16] In addition, Jaeger et al. stated that the most common type of odontogenic cyst was periapical cyst (31%), the 2nd most common odontogenic cyst was paradental cyst (16.72%) in Brazil,[11] which was a different information from the rest of the reports.
Table 3: Demographic data and localization of odontogenic cysts reported by number of countriesThe present study revealed that the odontogenic cysts occurred mostly in the 5th decade, while they occurred at younger ages in Mexican,[6] Indian,[9] and Iranian[16] populations (2nd–3rd decade of life). Gender distribution indicated that male population had predominance in odontogenic cysts series (58%) which was in accordance with the studies reported in other countries such as Mexico, Italy, India, Kenya, Greece, Turkey, Italy, and Iran (ranging between 50.9% and 64.4%).[6],[7],[8],[9],[10],[15],[16],[17] On the contrary, female predominance was significant only in Brazilian population.[12],[13] Moreover, this study revealed that odontogenic cysts were mostly located in the posterior part of mandible (52.89%), followed by anterior part of maxilla (24.41%). These regions were reported as the most common locations for odontogenic cysts in other studies as well.[6],[7],[9],[10],[11],[12],[13],[14],[15] However, Kilinc et al. from Turkey reported similar incidence rates for odontogenic cysts in anterior maxilla (33.5%) and posterior mandible (33.3%).[17]
The frequency of odontogenic tumors also differed among countries.[18],[19],[20] In the present study, the frequency of odontogenic tumors was 5.82% (n:43) and the most common type of odontogenic tumors was odontoma (65.12%), followed by ameloblastoma (11.63%). Similarly, Farias et al. reported odontoma as the most common tumor, followed by ameloblastoma[13] while several studies presented odontogenic keratocystic as the most common odontogenic tumor and ameloblastoma as the 2nd common odontogenic tumor.[18],[19],[20],[21] In our opinion, this situation may be due to the fact that odontogenic keratocyst was previously listed in the odontogenic tumor section in the 3rd WHO edition [Table 2].
In the present study, odontogenic keratocyst was determined to be the 3rd most common odontogenic cyst (13.7%) according to the latest classification of WHO declared in 2017 and was frequently located in the posterior region of the mandible. Incidence of odotogenic keratocysts peaked in the 5th decade and they were most frequently found in male population. Similarly, Tamiolakis et al. reported odontogenic keratocyst as the 4th most common odontogenic cyst (8.2%) and mostly located in the posterior region of the mandible. They were mostly seen in the 5th decade and male population.[15] However, Bhagwat et al. from India stated that the most common localization of odontogenic keratocyst was maxillar posterior region. In addition, it was often found in the 3rd decade and male patients.[18]
The frequency of all types of odontogenic tumors was reported to be between 4.79 and 11.9% in the studies from India, Brazil, Iran, and Malaysia based on the 3rd WHO edition[1],[18],[19],[22] and it was 5.82% in the present study based on the 4th edition of WHO. [Table 4] contains a list of the data including demographic data and localization of odontogenic tumors reported by different countries. Based on the previous classification, odontogenic tumors occurred mostly in 2nd, 3rd, and 4th decades of life[1],[18],[19],[20],[23] while they occurred mostly in the 6th decade in this study. Furthermore, odontogenic tumors were mostly located in the mandible in the previous studies.[1],[19],[20],[22],[23] Unlikely, maxilla and mandible was affected almost equally by odontogenic tumors in Indian population.[18] While number of studies including the present study[18],[20],[22],[23] reported that odontogenic tumors were more common in male patients, studies from Brazil[19] and Iran[1] reported that these tumors were more common in female patients.
Table 4: Demographic data and localization of odontogenic tumors reported by number of countriesOnly 7 (0,95%) malignant tumors were detected in this study which was a quite rare rate. These were primary intraosseous squamous cell carcinoma, metastatic adenocarcinoma, and mucoepidermoid carcinoma. None of them had an odontogenic origin. When similar studies were evaluated, most of the odontogenic tumors reported from India,[18] Brazil,[19] Italy,[20] and Malaysia[22] were benign. However, the prevalence of malignant odontogenic tumor in the study from Ethiopia[23] was quite higher (19%) than the rest of the studies.[18],[19],[20],[22]
Conclusion The present study assessed the demographic and clinical characteristics of odontogenic cysts/tumors in a group of Turkish people who visited GUSD for therapeutic purpose in the past 10 years. Results showed that the male patients in their 5th–6th decade of life have the highest risk of odontogenic cyst/tumor, especially in the mandibular posterior region. However, our study was carried out in a single center. Therefore, multi-centered and more extensive studies with a larger patient series are needed for a better feedback of demographic distribution and clinical features of odontogenic cysts and tumors in Turkish population.
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Conflicts of interest
There are no conflicts of interest.
References 
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