“LEVELS OF ALBUMIN, PREALBUMIN, TOTAL PROTEIN, INORGANIC PHOSPHATE AND PRESENCE OF KERATINOCYTES IN THE CYSTIC FLUID OF ODONTOGENIC KERATOCYSTS (KERATOCYSTIC ODONTOGENIC TUMORS) IN COMPARISON TO NONKERATINISING ODONTOGENIC CYSTS”
BRIEF RESUME OF THE INTENDED STUDY: 6.1) NEED FOR THE STUDY: Odontogenic keratocyst (Keratocystic odontogenic tumor) is a clinicopathologically distinct form of odontogenic cyst, known for its pathognomic microscopic features, aggressiveness and high recurrence rate.
Odontogenic Keratocysts classically exhibit several characteristic histologic features; a uniform thickness of epithelial lining composed of 6-10 cell layers with a well polarized basal cell layer and a parakeratinised luminal surface that is usually corrugated1
This lesion is now categorized as an odontogenic tumor according to the latest WHO recommendations because the mitotic activity of the epithelial cells is greater than that of odontogenic jaw cysts2.
Conservative methods of treatment such as enucleation and marsupilization, consistently have produced less than optimal results in OKC compared to that of nonkeratinising odontogenic cysts like dentigerous cyst and radicular cyst. Hence various surgical modalities were advised for an attempt to improve the recurrence rate like curretage, peripheral ostectomy, osseous reconstruction with or without continuity defect3.
Preoperative diagnosis of OKC improves the treatment outcome in formulating an appropriate treatment plan and adequately counseling the patients3.
Studies have reported significant differences between the concentration of total protein, prealbumin, albumin as well as keratin and keratinocytes levels in cystic fluid of OKCs and other forms of odontogenic cysts4.
Very few studies have been conducted to determine the levels of inorganic phosphate and cytological aspects of the fluid for the preoperative diagnosis of the odontogenic keratocyst.
Hence the present study is planned to evaluate the level of albumin, prealbumin, total protein, inorganic phosphate and presence of keratinocytes in the cystic fluid to diagnose and appropriately plan the treatment of odontogenic keratocysts and other odontogenic cysts.
6.2 REVIEW OF LITERATURE:
The fluid of 44 dental cysts, 19 dentigerous cysts, 36 odontogenic keratocysts and 12 ameloblastomas have been investigated. The incidence of epithelial cells, inflammatory cells, cholesterol crystals and bacteria was recorded in smears. There was high incidence of epithelial cells and albumin levels in OKC and not in other lesions. The amount of total protein level was low as compared to other cysts4.
Cystic fluid from 17 odontogenic keratocysts and 71 non-keratinizing dental cysts was analysed for major fraction with a mobility anodal to albumin on electrophoresis. They found that the fluid contained a lower concentration of soluble protein. The prealbumin band seen in 7 of the 17 odontogenic keratocysts was not seen in a series of 71 non-keratinizing dental cysts5.
Cystic fluid from 8 odontogenic keratocysts was obtained using fine needle aspiration technique. Cytologically many isolated or groups of keratinocytes with normal or ill-defined nuclei were seen, besides numerous anucleated squamous cells and keratinous debris6.
Fluid aspirates from 65 cysts and 2 cystic ameloblastomas were examined. Gylcosaminoglycans and proteoglycans were analysed in keratinizing and non keratinizing odontogenic cysts fluids. They concluded that hyaluronic acid showed the highest incidence and abundance amongst the gylcosaminoglycans detected. Heparan sulphate showed the highest incidence and abundance in keratinocytes than the other cysts7.
Fluid from 29 radicular cysts, 12 dentigerous cysts and 27 keratocysts was investigated using qualitative and quantitative immunodiffusion method. They found that the presence of lactoferrin in aspirates of odontogenic cyst fluid might be a useful preoperative diagnostic marker for odontogenic keratocysts8.
6.3 AIM OF THE STUDY
To evaluate the levels of albumin, prealbumin, total protein, inorganic phosphate and presence of keratinocytes in the cystic fluid to diagnose and appropriately plan the treatment of Keratocystic odontogenic tumors and other odontogenic cysts.
6.4 OBJECTIVES OF THE STUDY
To study the albumin, prealbumin and total protein level in cystic fluid using fine needle aspiration
A cyst which is showing classical features of Odontogenic Keratocyst after histopathological examination.
Histopathologically diagnosed Nonkeratinising odontogenic cysts like Radicular cyst, Dentigerous cyst, Lateral periodontal cyst and Residual cyst.
Cysts which show malignant changes in any part of the epithelial lining.
A lesion which does not show classical histopathological features of cysts at any part of the lesion.
Other keratinizing cyst like Calcifying Epithelial Odontogenic cyst.
7.2 METHOD OF COLLECTION OF DATA Cystic fluid is aspirated using an 18 gauge needle from the most prominent and fluctuant part of the swelling by fine needle aspiration technique.
1ml of the fluid is used for biochemical evaluation for the estimation of total protein, prealbumin, albumin using gel electrophoresis method and inorganic phosphate levels using Fiske Subbarao method.
The remaining cystic fluid is transferred to a clean dry centrifuge tube. The tube is placed for centrifugation at 1500rpm for 10 min. Following centrifugation, the cells appear at the base of the centrifuge tube as a cell button. The supernatant is then poured off carefully into a suitable disinfectant. The resulting cell suspension is carefully removed using a pipette, and a single small drop is placed towards one end of a clean, labeled glass slide. The material is rapidly spread using another glass slide.
3 smears are prepared using the above method. For Hematoxyline & Eosine stain and Papanicolaou (PAP) stain, the smears are fixed immediately in ether alcohol. For May Grunweld Giemsa stain (MGG) (Romanowsky stains), the smears are air dried and then fixed in methanol.
The smears are stained with May Grunweld Giemsa (MGG) (Romanowsky stains), Hematoxyline and Eosine stain and Papanicolaou (PAP) stain. The stained sections are examined under light microscopy for keratin and keratinocytes.
After surgical excision of the cystic lining, the tissue is processed and sectioned using paraffin embedded technique for confirmation of the diagnosis.
The data collected will be statistically evaluated using Mann Whitney U Test and Students ‘t’ test.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED IN PATIENTS OR OTHER HUMANS OR ANIMALS?
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION :
Yes, ethical clearance has been obtained and the letter is enclosed.
LIST OF REFERENCES
Rodu B, Tate AL, Martinez Jr MG. The implications of inflammation in odontogenic keratocysts. Journal of Oral Pathology and Medicine 1987;16: 518-21
Pathology and Genetics of Head and Neck Tumours, Leon Barnes, John W. Eveson, Peter Reichart,David Sidransky, IARCPress Lyon, 2005: 306 – 307
M.Anthono Pogrel, MD, DDS, FRCS, FACS and Brian L. Schmidt, DDS, MD, PhD. Oral and Maxillofacial Surgery Clinics of North America; August 2003.
R. M.Browne, Some observations on the fluids of odontogenic cysts. Journal of OralPathology and medicine.1976; 5: 74-87
J Southgate, J.T Whicher, J.D Davies, D.St.J O’Reilly, and R.W Matthews. A protein of Squamous keratinizing epithelium from odontogenic keratocyst fluid; Virchows Arch (Pathol Anat) 1986; 409: 705-713
P.A Vargas, D.E. da Cruz Perez, G M Mata, O P de Almeida, A V Jones and R Gerhard. Fine needle aspiration cytology as an additional tool in the diagnosis of Odontogenic Keratocyst. Cytopathology 2007 Dec; 18(6): 361-66
G Smith, A J Smith and R M Browne. Glycosaminoglycans in fluid aspirates from odontogenic cysts. Journal of Oral Pathology 1984; 13: 614-621
A J Smith, J B Matthews, G I Mason, R M Browne. Lactoferrin in aspirates of odontogenic cyst fluid. Journal of Clinical Pathology 1988; 41: 1117-1119
Z J Sun, B Liu and Y F Zhao. Radiopacity in syndrome keratocystic Odontogenic tumor, Dentomaxillofacial Radiology 2008; 37: 175-178
Yoko Suyama, Yasutaka Kubota, Tomohiro Ninomiya, Kanemitsu Shirasuna. Immunohistochemical analysis of interleukin-Iα, its type I receptor and antagonist in keratocystic odontogenic tumors. Journal of Oral Pathology and Medicin 2008; 37: 560-564
Neville WB, Damm DD, Allen MC, Bouquot EJ. Oral and Maxillofacial Pathology, 2nd ed.: Elsevier, 2002; 589-609
SIGNATURE OF THE CANDIDATE
REMARKS OF THE GUIDE
Pilot study was done. The study may be done under my guidance.
NAME & DESIGNATION OF (In block letters)
PROF. (DR.) PUSHPARAJA SHETTY
HEAD OF THE DEPARTMENT
DEPARTMENT OF ORAL PATHOLOGY & MICROBIOLOGY
A.B.SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES, DERALAKATTE, MANGALORE- 575 018.