|Year : 2017 | Volume
| Issue : 2 | Page : 76-81
Profiling of odontogenic tumors in western Uttar Pradesh population in India
Suhasini Palakshappa Gotur1, Vijay Wadhwan1, Pooja Aggarwal1, Vandana Reddy1, Preeti Sharma1, Nagaraju Kamarthi2
1 Department of Oral Pathology and Microbiology, Subharti Dental College, Meerut, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, Subharti Dental College, Meerut, Uttar Pradesh, India
|Date of Web Publication||8-Jan-2018|
Dr. Suhasini Palakshappa Gotur
Subharti Dental College, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objective: This institutional study was sought to determine the relative frequency of odontogenic tumors (OTs) in a western Uttar Pradesh population and to compare these data with previous reports.
Study Design: In this retrospective study, all the accessioned cases were retrieved from the histopathology records of Subharti Dental College and Hospital between January 2003 and December 2015. Lesions with histological diagnosis of OTs (based on the World Health Organization classification, 2005) were analyzed. Clinical data were reviewed, and microscopic diagnoses were confirmed for cases in which diagnoses were ambiguous. The relative incidence of each tumor type, patient age, gender, and site of occurrence are compared with similar reports from other selected large series.
Results: From a total of 3182 oral biopsies accessioned during 13-year interval, 255 lesions were diagnosed histopathologically as OTs, which constituted 8.01% of all the oral biopsies. Of these cases, 98.43% of the tumors were benign. The most frequent histological type was keratinizing cystic OTs (41.96%), followed by ameloblastoma (34.50%) and while odontomas, generally regarded as the most frequent OT in many large series, only accounted for 7.45%, the third most common tumor in the present study. In general, the OTs showed a predilection for the mandible and the posterior regions of the jaws. Males outnumbered females for benign tumors while the reverse was true for malignant tumors.
Conclusions: OTs show a definite geographic variation. In western Uttar Pradesh population in India, the most frequent OTs had a comparatively younger age predilection.
Keywords: Ameloblastoma, epidemiology, keratinizing cystic odontogenic tumor, odontogenic tumor
|How to cite this article:|
Gotur SP, Wadhwan V, Aggarwal P, Reddy V, Sharma P, Kamarthi N. Profiling of odontogenic tumors in western Uttar Pradesh population in India. Int J Oral Health Sci 2017;7:76-81
|How to cite this URL:|
Gotur SP, Wadhwan V, Aggarwal P, Reddy V, Sharma P, Kamarthi N. Profiling of odontogenic tumors in western Uttar Pradesh population in India. Int J Oral Health Sci [serial online] 2017 [cited 2019 Nov 20];7:76-81. Available from: http://www.ijohsjournal.org/text.asp?2017/7/2/76/222394
| Introduction|| |
Odontogenic tumors (OTs) are a group of lesions that arise from the epithelial, ectomesenchymal, and/or mesenchymal elements derived from the tooth-forming apparatus. They are thus exclusive to the jaws, with a relatively rare frequency of 1% and represent the only situation in pathology where a primary epithelial tumor may be found within the bone. The biological behavior of these lesions ranges from hamartoma-like lesions and benign neoplasms to rare aggressive malignant tumors.
The first major attempt to classify OTs was published in 1971 after a 5-year collaborative effort, organized by the World Health Organization (WHO). An updated second edition of the WHO classification was published in 1992. There were still controversies over terminology and classification, and therefore, in 2005, the WHO published an updated third edition for the definition and typing of these tumors. There were six major changes in the new classification compared with the previous version: (1) parakeratinized odontogenic keratocyst is now classified as benign tumor derived from odontogenic epithelium and termed keratinizing cystic OT (KCOT); (2) adenomatoid OT (AOT) originates from odontogenic epithelium with mature fibrous stroma but not with ectomesenchyme; (3) calcifying odontogenic cyst (COC) is divided into two benign groups and one malignant group; (4) clear cell OT is in fact a malignant lesion and termed clear cell odontogenic carcinoma; (5) odontogenic carcinosarcoma is not included owing to lack of evidence for its existence as an entity; and (6) some changes are made regarding terminology and subtypings.
Several retrospective studies carried out in Africa, Asia, Europe, and America show that differences exist in the relative frequency of various histological types.,,,,,, Considering the colossal population concentrated in India, there are only a few demographic studies on OTs in northern states of the country, especially Uttar Pradesh which is one among 10 most thickly populated states in India (with a population of approximately 199 million as of March 1, 2011, according to 2011 census) requires more demographic studies which could serve as a potential source of information to understand the role of regional or geographic variations.
The present study was sought to provide demographic data on OTs and to determine the relative frequency and distribution regarding gender, age, and tumor site of OTs in a western Uttar Pradesh population and to compare these data with previous reports.
| Material and Methods|| |
After obtaining the institutional (Subharti Dental College and Hospital) ethical clearance, all the accessioned cases were retrieved from the histopathology records of the Department of Oral and Maxillofacial Pathology and Microbiology of the Subharti Dental College and Hospital during the period January 2003–December 2015. The lesions classified as OTs during the period were reviewed and re-evaluated with the hematoxylin- and eosin-stained sections, and the diagnosis in each case regarding histopathological typing was confirmed or modified, according to the latest WHO classification. These cases were analyzed for clinical data regarding age, gender, site of tumor, and duration. Bone-related lesions and other tumors were not included in this study.
Follow-up information found in the records was limited, which may be attributed to illiteracy, poor awareness on health issues, lack of motivation, and poverty in this region. In the cases of multiple biopsies, the histology of the excisional biopsy was considered and counted as a single case. In case of recurrent tumors, the histology of the original and the recurrent tumors was compared and they were considered as one individual case. With regard to the site of occurrence, each jaw was divided into three parts: anterior, premolar, and molar. In the case of the mandible, the molar area also included the angle and ramus. Any tumor involving two areas or more was assigned to the region approximating the center of the lesion.
The data were analyzed and descriptive statistics were employed for gender, age of occurrence, and anatomical location.
| Results|| |
From a total of 3182 oral biopsies accessioned during 13-year interval, 255 lesions were diagnosed histopathologically as OTs, which constituted 8.01% of all the oral biopsies.
Frequency and gender distribution
Among all the OTs included in the study, the incidence of OTs in males was 148 and in females was 107, with a ratio of 1.38:1. Of these OTs, 251 were benign and the only four malignant tumors were ameloblastic carcinomas (ACs) [Table 1]. Among the benign tumors, KCOT was the most common tumor, followed by ameloblastoma (AM) and odontoma (OD), with all these three most common tumors in the present study showing a male predominance. The most common variant of AM in the present study was solid multicystic (61 cases) followed by unicystic (27 cases). The study group also included three cases of desmoplastic AM [Table 2]. AOT, ameloblastic fibro-odontoma (AFO), ameloblastic fibroma (AF), odontogenic fibroma (OF), odontogenic myxoma (OM), and AC showed predilection toward female in the present study. Calcifying epithelial OT (CEOT), odontoameloblastoma (OA), OF, AF, cementoblastoma (CB), and AC were the tumors with least frequency.
The OTs in the present study showed a wide range (7–79 years) of age distribution with highest incidence in the second and third decades [Table 3].
The [Table 4] shows a predilection of odontogenic tumors for mandible (maxilla: mandible ratio - 1:2.493), in general, except for AOT, AFO, and OD which showed a preponderance to maxilla in the study. The most common site of occurrence was the mandibular molar region, followed by mandibular premolar region. In maxilla, molar region was the most common site of occurrence of OTs, followed by anterior region. However, AOTs were seen exclusively in anterior-premolar region both in the maxilla and mandible.
| Discussion|| |
The present study represents the first large series study from North India, in Uttar Pradesh population. To the best of our knowledge, there are only a few studies published in the English literature which followed the new WHO 2005 classification.,,,,,,,, The reported incidence of OTs worldwide ranges from 1% to 32%., This supports the incidence of OTs (8.01%) in the present study.
In the present study, all the cases were found in patients older than 7 years which is in accordance with previous studies. In most permanent teeth, crown formation completes by the age of 4–5 years which indicates that OTs probably develop after crown formation. This strengthens the fact that majority of OTs arise from quiescent remnants of the tooth germ.
In the present study, the benign OTs comprised of 98.43% of all OTs reported in the institute, which is in accordance with most of the previously reported studies.,,,,,,,, Most of the previous reports show a male predominance which was consistent with our study also with a male to female ratio of 1.38:1. However, a female predominance , and equal gender distribution  are also reported. In general, the OTs in the present study showed a site predilection toward the mandible, in accordance with the most other reports.,,
According to the studies which are based on the WHO 2005 classification, the most common OT in six of these studies was the AM, the second most common tumor being KCOT followed by OD.,,,,, Only a few studies showed KCOT as the most common OT., It is interesting to note that the frequency of AM in comparison to other OTs has reduced significantly, as a result of the inclusion of OKC as a benign tumor in the 2005 WHO classification. In the present study, KCOT outnumbers the AM, with a frequency of 41.96% of all OTs. The peak incidence of occurrence of KCOT is in the second and third decades of life, consistent with other studies. The gender and site distribution were in accordance with the previous literature. Three cases showed recurrence in the study period.
AM occurred less frequently than KCOT in the present study, with a frequency of 34.509%. This observation is in contrast with the studies reported from other geographic regions.,,,,, Mandibular molar area was the most commonly affected site as with other large series ,,, and with a male prevalence which is in agreement with many other studies , but in contrast with some reports.,
In the present study, relative predominance of KCOT and AM seen may be attributed to the disfigurement or symptoms associated with these lesions as compared to generally asymptomatic ODs. This situation may also be attributed to the referral of the therapeutically difficult extensive lesions such as AM and KCOTs as compared to ODs which are likely to be diagnosed and treated by local hospitals.
It is interesting to note that in the present study group, the peak incidence of occurrence of OT is in the second and third decades of life, and the mean age of occurrence for AMs is much lower as compared with other studies., Few authors reported that persons from developing countries develop AMs 10–15 years earlier than in industrialized countries and proposed that this variation among countries may be due to the accelerated aging process in developing countries owing to poor nutrition and health care., In our study, the incidence of follicular type of AM was more common than plexiform AM, consistent with previous reports.
OD accounted for 7.45% of all OTs with relatively less frequency which is one of the noteworthy differences in our series compared with other large series. OD was the most common OT reported in the Western world, in a study which followed the new classification. This discrepancy may be due to geographic variation. Further, as these lesions are asymptomatic and exhibit self-limited growth, many patients may not seek a dentist. Treatment in many cases may be carried out by local dentists, and the cases might not be registered or sent for histopathological confirmation. In the present study, 84.21% of cases were less than 30 years of age, consistent with many other reports., Male predominance is seen in the present study, contradicting female predominance found in few studies.,
AOT accounted for 2.745% of all OTs with a relative female predominance in the anterior maxilla, which is in accordance with the previous studies. However, studies with higher frequencies are also reported. AOT occurred in a relatively younger age group, in conformity with previous studies.,,, The peak incidence (85.71%) was found in the second decade of life.
COC shows great diversity in structure and behavior. In this series, there were seven cases of COC with male preponderance similar to previous reports., These tumors occurred more commonly in the posterior mandible similar to a study  and contradicting other study. However, it is difficult to compare these data with findings from previous reports because different histological criteria were used by different authors when classifying these lesions.
OM occurred with a frequency of 2.745% and preponderance in females similar to previous studies. This relative frequency is seen in other studies also ranging from 4.7%–17.7%.,,, There was a slight mandibular predilection seen in the present study, similar to other reported studies.,
AFO had a frequency of 1.96% in the present study which is higher compared to other studies,,, with younger age predilection, analogous to older studies,,, with a slight female, and maxillary proclivity.
The incidence of CB (1.56%) in this series is similar to that seen in previous reports , though studies with higher frequencies are also reported. AC matched CB in frequency.
All three cases of AF occurred in the mandible, representing that 1.176% of all the OTs in this study were an uncommon tumor type in this series, similar to previous reports.,, However, its frequency was apparently lower than in few populations. The female predominance, younger age of occurrence, and mandibular predilection of this neoplasm were similar to those previously reported.,
There exists a view about a possible interrelationship between AF/ameloblastic fibrodentinoma (AFD)/and ODs. Cahn and Blum  proposed the “continuum concept,” stating that AF may mature over time, eventually leading to the formation of an OD. However, Reichart et al. proposed two reasons for the refusal of the continuum concept. First, there is no evidence of further differentiation and maturation into a more developed OT in residual or recurrent cases of AF, and second, AFs are known to occur at ages well beyond the completion of odontogenesis. In the present study, we observed the age overlap in cases of AF, AFO, and ODs. This finding does not lend support to the continuum concept. However, this observation needs confirmation based on a much larger case series.
The incidence of OF (0.78%) is similar to previous reports though studies with higher frequencies are also reported.,
The rarity of CEOT (0.39%) was comparable to the findings reported in previous literature, and comparisons are, therefore, futile. OA was one among the uncommon tumor types in this series, confirming the rarity of these tumors. No conclusions could be drawn regarding gender, age, and site predilection owing to the paucity of cases regarding CEOT, OA, OF, CB, and AC.
There were no cases of squamous OT, AFD, and odontogenic sarcomas diagnosed in the study duration, owing to the dearth of their occurrence. Although there is no mention of mixed OT in the WHO classification, we found one case of mixed OT in our archive (with both the features of plexiform AM and CEOT), and as we were unable to categorize this tumor in the existing WHO classification, it is excluded from the study group. Peripheral (extraosseous or soft tissue) OTs are rare lesions that occur in the soft tissue overlying the tooth-bearing areas of the mandible and the maxilla. There is only scarce information in the literature on the relative frequency of peripheral OTs, and reports in the literature have mainly been single case reports or a small series of cases. However, in the present study, no peripheral OTs were seen.
It was very difficult to make a valid comparison between the published studies about relative frequencies of OTs, owing to the changes that have occurred over the years in the classification of OTs, such that some of the pathologic entities have changed their definitions and some new ones have been introduced. Moreover, most of the published large series studies were conducted before the 2005 WHO classification of OT which was used in this study, a situation that does not allow an appropriate comparison to be made.
| Conclusion|| |
This study provides baseline epidemiological information on geographic variations in the incidence of OTs in North Indian population. The knowledge of these data will be helpful in understanding these lesions, which allows clinician to ascertain proper diagnosis. Although the present study was based on the institutional data, considering the large number of outpatients which equals any of the government dental health-care settings and the patients from all kinds of socioeconomic strata visiting the institution, the institutional sample could be fairly taken as the representative sample of western Uttar Pradesh. However, the real population difference regarding the incidence and basic clinical presentation is unknown, and further studies across different populations may prove helpful in supporting these demographic profiles of OTs.
We would like to acknowledge the Management and Principal, Subharti Dental College, for providing the infrastructural support.
Financial support and sponsorship
Conflicts of interest
There are no conflflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]