Topical 5-fluorouracil application in management of odontogenic keratocysts

Comparing 5-Fluorouracil Versus Modified Carnoy's Solution for the Treatment of Odontogenic Keratocysts: A Systematic Review and Meta-Analysis

PURPOSE

The primary aim of this study was to compare time to odontogenic keratocyst (OKC) recurrence with 5-fluorouracil (5-FU) versus modified Carnoy's solution (MCS) following enucleation and curettage and peripheral ostectomy. The secondary aim was to compare the frequency (%) of permanent peripheral nerve injury characterized by hypoesthesia and neuropathic pain present at 12 months or more after surgery with 5-FU versus MCS.

METHODS

The Cox hazard ratio was calculated to compare time to recurrence between the 2 groups. To compare the frequencies of permanent nerve damage, we fitted a fixed-effects model to the data and calculated the risk ratio. Other variables collected were sex, age, follow-up time, and cyst size.

RESULTS

No significant differences in sex, age, follow-up time, and cyst size were found. The median follow-up time for all patients was 60 months (range: 12-180 months, Q1 = 32 months, Q3 = 86 months, interquartile range = 54 months). Of the 114 patients treated with MCS, 27 recurrences with a median recurrence time of 42 months (range = 12-108 months, Q1 = 26.3 months, Q3 = 54 months, interquartile range = 27.7 months) were recorded; no recurrences were observed among the 99 patients treated with 5-FU (hazard ratio = 0.02, 95% CI = 0.00018-0.16, P = 2.27e-07). Of the 112 patients treated with MCS, there were 20 (17.86%) instances of permanent peripheral nerve injury; of the 98 patients treated with 5-FU, there were 7 (7.14%) instances of permanent peripheral nerve injury (risk ratio = 0.44, 95% CI = 0.20-0.97, P = .04).

CONCLUSION

The results of this meta-analysis significantly favored 5-FU over MCS for lower OKC recurrence and peripheral nerve injury, supporting the use of 5-FU as the superior adjuvant following enucleation and curettage and peripheral ostectomy for the treatment of OKCs.

The Role of 5-Fluorouracil in Preventing Recurrence After Enucleation of Odontogenic Keratocyst: A Case Report

The odontogenic keratocyst (OKC) is known for its high recurrence rate and disputed treatment modalities. In this report, we review the literature elucidating the efficacy of 5-fluorouracil (5-FU) topical application for recurrent OKC, and discuss the management of an OKC with 5-FU after enucleation and a 12-month follow-up. A 38-year-old female patient with an aggressive OKC in the right mandible underwent surgical curettage followed by topical application of 5-FU. Regular follow-up examinations for 12 months (radiological evaluation at three, six, and 12-month intervals) showed no signs of recurrence, with complete resolution of the cystic lesion and gradual bone regeneration. New bone formation was identified in the radiographic follow-up.  This case demonstrates the potential efficacy of topical 5-FU as a promising treatment modality for OKC, warranting further research and validation. A novel and successful therapy for OKC is the topical application of 5-FU. After enucleation, topical application of 5-FU efficiently treats OKC, leading to normal bone healing and regeneration without any adverse local or systemic effects.

5-fluorouacil in the treatment of odontogenic keratocysts-incidence of recurrence and inferior alveolar nerve paresthesia: a systematic review

PURPOSE

To evaluate the recurrence rate of odontogenic keratocyst (OKC) after treatment with 5-fluoracil as an adjunctive therapy and to evaluate, as well, the efficacy of this medication in reducing the incidence of inferior alveolar nerve paresthesia associated with other chemotherapeutic agents.

MATERIAL AND METHODS

The research question (developed according to the patient/population, intervention, comparison, and outcomes [PICO] method) addressed was "Does the use of 5-fluorouracil as an adjunctive therapy in the treatment of OKC reduce both the recurrence rate and the incidence of inferior alveolar nerve paresthesia as compared with other chemotherapeutic agents?" A systematic review was performed by searching 4 databases: PubMed, EBSCO, Portal Evidencia, and Cochrane Reviews. Each search was conducted twice. Two independent reviewers evaluated the data. For each database, a search strategy was developed that included the following generic terms: Fluorouracil, 5-Fluorouracil, or liquid nitrogen and odontogenic cyst or odontogenic keratocyst. Three filters were applied to the searches, as well, consisting of the terms clinical trials, English papers, and Spanish papers.

RESULTS

Of the 74 papers retrieved. The titles and abstracts of the selected papers were reviewed to determine whether those papers were relevant to our research question; only 3 papers were selected for this systematic review: 2 retrospective cohort studies and 1 clinical trial. Assessments risk bias and the quality of evidence were performed.

CONCLUSIONS

The risk of bias and quality of evidence in this systematic review are moderate due to the study's design, although the clinical results were excellent with respect to the reduction of both OKC recurrence and paresthesia associated with this kind of cyst.

Safety and efficacy of adjunctive therapy in the treatment of odontogenic keratocyst: a systematic review

The odontogenic keratocyst (OKC) is a common cystic lesion in the jaw. Its management, however, is highly debated with no consensus on the best treatment option. Clinicians base their approach on treatment efficacy and associated morbidity. Management often consists of enucleation with peripheral ostectomy and adjunctive therapy to prevent recurrence. The aim of our systematic review was to evaluate the safety and efficacy of these different modalities. Embase, Medline, and Cochrane were searched according to the PRISMA guidelines for articles that presented non-syndromic patients with histopathologically confirmed OKC treated with 5-fluorouracil (5FU), Carnoy's solution (CS), or modified Carnoy's solution (MCS) as adjunctive therapy after enucleation and peripheral ostectomy. The outcomes of interest were safety (measured as adverse events) and efficacy (expressed as recurrence). Risk of bias was evaluated using the Newcastle-Ottawa scale. Four studies were included and 62 patients were evaluated. The results show that recurrence occurred only in patients treated with MCS. Reported adverse events were mostly limited to paraesthesia that could be permanent (in the CS and MCS treatment groups) or transient (across all adjunctive therapies). With the prohibition of CS, both MCS and 5FU are promising replacement adjunctive therapies. From a safety and efficacy perspective we consider 5FU, which was associated with the lowest recurrence and fewest adverse events, to be the most viable option. More high-evidence prospective studies, such as randomised controlled trials, with a longer follow-up period are necessary to draw definite conclusions.

Comparison of the effectiveness of 5-Fluorouracil and modified Carnoy's solution in reducing the recurrence of odontogenic keratocyst

Introduction

Odontogenic keratocysts (OKC) has a high potential for recurrence. Resection is currently the only fool-proof method to ensure that recurrence does not occur; however, it drastically affects the patient's function and aesthetics. Application of modified Carnoy's solution (MCS) as an adjunct to reduce the recurrence rate is currently in vogue. 5- Flurouracil (5-FU) is an anti-metabolite that has been used in the treatment of basal cell carcinoma and is relatively safer than MCS. The present study aims to compare the effectiveness of 5-UC and MCS in reducing the recurrence rate in OKC..

Material and methods

A total of 42 OKCs were enucleated followed by application of MCS (control group, n = 21) or 5-FU dressing (study group, n = 21) following enucleation. Pain, swelling, temporary and permanent paresthesia paresthesia, bone sequestrum formation, osteomyelitis and recurrence in both groups were evaluated at periodic intervals up to 12 months post-surgery.

Results

There was no significant difference in terms of pain, or swelling in both groups. Permanent paresthesia and recurrence rates were higher in patients treated with MC but the difference was not statistically significant.

Conclusion

5-FU is an easy-to-use, feasible, biocompatible and cost-effective alternative for MCS in the management of OKCs. Treatment with 5-FU, therefore, reduces the risk of recurrence and also the post-surgical morbidity associated with other treatment procedures.

Antimetabolite in the Management of Odontogenic Keratocyst-A Case Report

Odontogenic keratocyst (OKC) is an aggressive cystic lesion of the jaw with high growth and recurrence. Patients are usually asymptomatic and detected during routine radiographic examination. Management of OKC varies from conservative procedures like simple Enucleation and peripheral ostectomy to aggressive resection. More attention is given to new treatment protocols to form them simple and successful. 5 fluorouracil is an anti-metabolite used to treat basal cell carcinoma and other malignancies act by inhibiting thymidylate synthase an enzyme required for DNA synthesis causing cell death. This is a case report of a 40-year-old female patient with OKC treated with topical 5 fluorouracil after enucleation, has less morbidity minimal recurrence, and low cost.

Combined conservative treatment of a recurrent mandibular keratocyst by enucleation, diode laser, 5-Fluorouracil and dental implants: a case report with 18 years-follow up

In 2017, the World Health Organization classified the odontogenic keratocyst as a developmental odontogenic cyst. The posterior parts of the mandible, especially the angle and the ramus, are the most involved sites. Due to their high recurrence rate, keratocysts are managed surgically with careful complete excision. Additionally, chemical solutions such as Carnoy's solution, modified Carnoy's solution, and 5-Fluorouracil have been associated with surgical treatment. Diode lasers generate diverse wavelengths that have photothermal and photochemical special properties and could have some effects on the lining epithelium remnants of the cyst. In this paper, we discuss a case of mandibular recurrent odontogenic keratocyst treated with 5-Fluorouracil topical application after enucleation and diode laser application with 18 years follow-up and teeth replacement with dental implant. 5-Fluorouracil and diode laser have been found to be very effective in the treatment of keratocysts.

Effectiveness of different treatments for odontogenic keratocyst: a network meta-analysis

Odontogenic keratocysts (OKC) are benign but aggressive lesions. As there is a lack of well randomized clinical studies assessing the effectiveness of the different treatment options for OKC, a network meta-analysis (NMA) was performed to identify the best treatment option with the lowest recurrence rate. An electronic search was performed following the PRISMA guidelines to identify all clinical studies comparing treatment options against enucleation alone. The outcome variable was recurrence. The predictor variables were treatments. The eight included treatments were: enucleation with peripheral ostectomy/curettage (E + PO/curettage); enucleation with cryotherapy (E + CRYO); enucleation with/without PO followed by modified Carnoy's solution (E ± PO+MCS); enucleation with PO and with topical 5-fluorouracil (E + PO+5FU); enucleation with/without PO followed by original Carnoy's solution (E ± PO+CS); marsupialization alone (MARS); marsupialization followed by secondary enucleation with/without PO (MARS+2°E ± PO); and resection. The odds ratio was used to estimate the recurrence rate. A frequentist NMA was performed using Stata software. A total of 2989 patients in 40 studies were included. Both direct pairwise meta-analysis and NMA showed that E + 5FU+PO was significantly superior to E ± PO+MCS. However, no statistically significant difference was found between E ± PO+CS vs E + 5FU+PO, E ± PO+MCS, and resection, respectively (all very low quality evidence). The three most effective treatments in reducing the recurrence rate were E + PO+ 5FU (98.1%; very low quality evidence), resection (83.5%; very low quality evidence), and E ± PO+CS (63.8%; moderate quality evidence). The findings from this study suggest that CS remains the most effective fixative agent after enucleation and PO until proven otherwise. Additionally, 5FU appears to be an effective method with promising results that needs further research. Finally, the efficacy of MCS remains controversial; further in vivo and in vitro studies are required to determine new protocols. As this NMA included retrospective studies, the results should be interpreted with great caution (level of evidence: type III).

An evidence-based surgical algorithm for management of odontogenic keratocyst

The effective management of odontogenic keratocyst (OKC) remains a subject of interest and confusion in the oral and maxillofacial surgery literature. Currently, there is a lack of consensus regarding the most appropriate treatment for patients with OKC. Of the various treatment options available, no modality to date has been shown to demonstrate a zero or near-zero recurrence rates except wide resection with clear margins. With the prevailing dearth of evidence based surgical protocols for the management of patients with OKC in the literature, this study aims to present a surgical algorithm, based on meta-analysis results, that hopefully will be beneficial in enhancing treatment of patients with this condition. Also, new meta-analysis was done to compare between modified Carnoy's solution (MCS) and 5-fluorouracil (5-FU) in respect of recurrence rate of OKC. Using parameters like size, lesion type (primary or secondary), syndromic or solitary nature of the lesion, presence of cortical perforations, and locularity; we present a decision tree, to aid treatment planning and help attain the least chance of recurrence in the management of the OKC. There was very low-quality evidence indicating that application of 5-FU, after enucleation and peripheral ostectomy of OKCs, significantly lowered recurrence rate when compared to MCS (RR = 0.087, CI: 0.017 to 0.436, P value = 0.003).

Modified Carnoy's Compared to Carnoy's Solution Is Equally Effective in Preventing Recurrence of Odontogenic Keratocysts

PURPOSE

Carnoy's solution (CS), the gold standard for adjunctive chemical cautery in treatment of odontogenic keratocysts (OKCs), has been banned for 7 years, leading to substitution with the non-chloroform containing modified Carnoy's solution (MC) without data to support its effectiveness. We performed this study to compare the earlier data with CS to the more current outcomes with MC.

METHODS

A retrospective cohort study was conducted on patients diagnosed with OKC and treated by a single surgeon (GHB) with enucleation and curettage (EC), peripheral ostectomy, and application of CS or MC. The primary predictor variables were use of CS or MC. The primary outcome variables were recurrence (yes vs. no) and time to recurrence. Secondary variables included demographics, anatomic location, and whether teeth adjacent to the lesion were extracted. Statistical analyses included chi-squared test/Fisher's exact test, Wilcoxon rank sum test, and Kaplan-Meier curves.

RESULTS

77 patients, 36 patients in the CS group and 41 in the MC group, met inclusion criteria, including at least 1 year of follow-up time. Characteristics of the groups were similar: median age 41.5 and 46, 61% and 71% male gender, 81% and 90% posterior, and 64% and 50% mandibular lesions, respectively. Overall recurrence was similar, 14.29%, with 5 (13.9%) recurrences in the CS group and 6 (14.6%) in the MC group (P = 0.92). Median time to recurrence was 24 months for both groups. Preserving adjacent teeth was associated with a significant increase in recurrence (P = 0.0036).

CONCLUSION

Based on this comparison of retrospective outcome data, we found no significant difference in recurrence rate or distribution of time to recurrence between OKCs treated with CS or MC. Aggressiveness of surgical technique is likely a predictive factor in recurrence rate. Future studies should focus on prospective studies and continuing follow-up of the MC group.