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NICO And Cavitations Print E-mail
by Dr. Wesley E.Shankland, Columbus, Ohio

Posted by Ron Kennedy, M.D., Santa Rosa, CA

History and Overview

Most people know what we mean when we say cavity, but the word cavitations is confusing. Both of these words come from the same root word meaning hole. A cavity is a hole in the tooth, whereas a cavitation is a hole in bone. Unlike most tooth cavities, bone cavitations can't be detected by simply looking at the bone, and even using x-rays many cavitations are missed. The termed cavitation was coined in 1930 by an orthopedic researcher to describe a disease process in which a lack of blood flow into the area produced a hole in the jawbone and other bones in the body. Dr. G.V. Black, the father of modern dentistry, described this cavitation process as early as 1915 when he described a progressive disease process in the jawbone, which killed bone cells and produced a large cavitation area or areas within the jawbones. He was intrigued by the unique ability of this disease to produce extensive jawbone destruction without causing redness in the gingiva (gums), jaw swelling, or an elevation in the patient's body temperature. Essentially this disease process, which produces osteonecrosis (dead bone) is actually a progressive impairment which produces small blockages (infarctions) of the tiny blood vessels in the jawbones, thus resulting in ostenecrosis, or areas of dead bone. These dead cavitational areas are now called NICO (Neuralgia Inducing Osteonecrosis) lesions. In his book on oral pathology, Dr. Black suggested surgical removal of these dead bone areas.

Location of Cavitations

In the last several years, the term cavitation has been used to describe various bone lesions which appear both as emtpy holes in the jawbones and holes filled with dead bone and bone marrow. The most common locations of cavitations are the areas of wisdom teeth (third molars) perhaps because these are the most commonly extracted.

Often, these NICO lesions take years to develop, usually producing few if any symptoms . . . for a while. Then, generally for unknown reasons, pain in the jaws, face, head and neck may develop. There are characteristic referred pain patterns, which generally confuse patients and doctors alike. However, pain may never develop and cavitations may be totally silent from a local symptom point of view.

NICO lesions don't develop just in the lower jaw or mandible. They also often occur in the maxilla or upper jaw as well, often spreading and penetrating the maxillary sinus.

Current Research

The results of recent research of Dr. Boyd Haley (Chairman, Department of Chemistry, University of Kentucky) show that ALL cavitation tissue samples he has tested contain toxins, which significantly inhibit one or more of the five basic body enzyme systems necessary in the production of energy. These toxins, which are most likely metabolic waste products of anaerobic bacteria (bacteria which don't live in oxygen), may produce significant systemic effects as well as play an important role in localized disease processes which negatively affect the blood supply in the jawbone. There are indications that when these toxins combine with certain chemicals or heavy metals (for example, mercury), much more potent toxins may form.

The results of research in Germany indicate the jawbone may be a holding tank for chemicals and heavy metals, especially at the wisdom tooth sites. Clinical experience indicates it is sometimes difficult for some patients to successfully detoxify mercury from the body until both the bone cavitations AND mercury fillings are removed.

Systemic Problems Associated With NICO Lesions

The term NICONeuralgia Inducing Cavitational Osteonecrosis — has been used when pains such as severe facial pain, neuralgia, headache, or phantom tooth pain accompany NICO lesions. Although bone cavitations are fairly common, only a small percentage (we think) suffer with pain. However, even those who have cavitational lesions with no apparent pain complaints may very well suffer from systemic problems never suspecting the relationship to cavitations. Researchers early in the 20th century, and now recently, have been concerned with systemic diseases caused by a primary problem (a focus of infection). The focal theory of infection fell out of favor with medical and dental doctors after the advent of antibiotics, but many researchers today believe that in spite of antibiotics, the focal theory of infection is alive and well. Ask any veterinarian doctor, and he or she will immediately agree that the focal theory of infection is a great concern of theirs.

In other words, many researchers today believe that NICO lesions are the focus of various infections which may spread throughout the body. In the last year or so, some of the most surprising medical news has been the discovery that bacteria from the mouth appear to be very influential in causing various heart problems. Could NICO lesions be associated with this phenomenon?

Occurence of NICO Lesions

With the use of an experimental device (the CAVITAT), cavitational lesions of various sizes have been discovered in 94% of wisdom tooth sites! Worse yet, the Cavitat found cavitations under 100% of teeth treated with root canal therapy in both males and females of various ages from several geographic areas of the United States. Do root canals also cause NICO lesions?

Initiating, Predisposing, and Risk Factors for NICO

There are many initiating, predisposing, and risk factors associated with cavitational lesions. It is likely that a combination of these factors present may influence the occurrence, type, size, progression and growth patterns of a cavitational bone lesion.

Initiating Factors: Probably the major initiating factors are dental trauma, which produce physical, bacterial, and toxic components, as described below.

Table 2: Dental traumas (initiating factors) associated with cavitational bone lesion development.

Physical Traum Bacterial Trauma Toxic Trauma
Tooth Extractions Periodontal Disease Dental Materials
Dental Injections Cysts Root Canal Toxins
Periodontal Surgery Abscesses Anesthetic by-Products
Root Canal Procedures Root Canal Bacteria Anesthetic Vasoconstrictors
Grinding and Clenching Avital (dead) Teeth Chemical Toxins
Electrical Trauma from Dissimilar Metallic Restorations Improper Removal of Periodontal Ligament after Tooth Extraction Bacterial Toxins
Heat from High Speed Drilling Infected Wisdom Teeth Other Toxins

Predisposing Factors: There are many predisposing factors and, no doubt, many more will be discovered. Most of the known predisposing factors include: blood clotting disorders such as thromophilia, hypofibrinolysis, or others; age - evidence suggests that as many as 11% of older persons may have major or complete blockage of arteries feeding the jaws or of the smallers arterioles within the jaws themselves; radiation or chemotherapy for cancer; rheumatoid arthritis; lymphoma or bone dysplasia; changes in atmospheric pressures in occupations; osteoporosis; systemic lupus erythematosis; sickle cell anemia; homocystinemia; Gaucher's disease; hyperlipidemia; hemodialysis; gout; antiphospholipid antibody syndrome; physical inactivity (bedridden); and deficienies of thyroid or growth hormones.

Risk Factors: There are many risk factors which greatly increase the probability of the development of cavitational lesions, especially in the occlusion or blockage of tiny blood vessels within the jawbones. The most common risk factors are: heavy smoking; high and long-term cortisone usage; pregnancy; estrogen use; alcoholism; and pancreatitis. Undoubtably, there are many other risk factors.

Wisdom Teeth Sites: Research findings indicate that 45% to 94% of all cavitational lesions are found at wisdom teeth extraction sites. These areas are anatomically predisposed to develop these bony lesions because they contain numerous tiny blood vessels which are apparently easily damaged from trauma (oral surgery in these areas) and osteonecrosis can easily develop. Also, many local anesthetic injections are given in the wisdom teeth areas and many of the local anesthetic solutions contain vasoconstrictors (especially epinephrine) which is used to intentionally close or shut-down the blood supply to the bone, teeth and gingiva to prolong the effects of the anesthetic and reduce bleeding. The actions of closing down the blood supply to these wisdom tooth areas may be a major cause for NICO development.

The Appearance of NICO Lesions

Cavitational lesions are difficult to discover. On most x-rays, unless the doctor is specifically trained, these bony lesions are usually missed.

Show a panorex x-ray to a dentist, oral surgeon or periodontist, and the doctor will proclaim the x-ray to be normal. The reason for this is that so many people have cavitations (thanks to "modern dentistry") they are considered to be normally present.

Imagine a lesion in a jawbone causing pain in a leg. These bony lesions can and do cause remote and systemic pains.

Recommended Treatment of Cavitational Lesions of the Jaws

The only treatment available at this time is surgical removal. Some have attempted to inject homeopathic remedies into these areas of dead bone, but unfortunately there is no blood circulation within cavitational lesions, so medications, drugs, or remedies can't get into and permeate these lesions let alone allow toxins and metabolic products to be removed. Homeopathic remedies certainly have their place in NICO treatment, especially in healing after surgical removal of the lesions themselves.

The surgery basically consists of making an incision, exposing the bony defects, and scraping them clean (termed debridement) to remove all unhealthy bone and other pathological problems like abscesses and cysts. It is not sufficient to simply punch a hole in the bone and rinse the area out, like some doctors recommend. In fact, treating these expanding bony lesions in such a conservative fashion often makes the lesion and subsequent pain much worse.

After removing the dead bone and other pathological products, the goal in healing is bone regeneration. But first, if possible, we remove all predisposing and risk factors.

What Can A Patient Do?

If you think you might have a NICO lesion, what can you do? First, find a doctor who understands this disease process; one who is trained in effectively diagnosing and treating these bony problems. Unfortunately, there are precious few such doctors.

Don't allow anyone to operate without first proving where your pain originates. This is done most effectively by closly evaluating x-rays and using diagnostic anesthetic injections to actually turn-off the suspected NICO areas to see if the pain is turned-off. There are characteristic referred pain patterns of NICO lesions and there are also characteristic responses to local anesthetic testing. Find a doctor who knows about these characteristic patterns and realize that most doctors who treat orofacial and TMJ pain know nothing about NICO lesions.

Dr. Shankland consults and treats NICO, orofacial, and TMJ patients. If you have any questions, please call Dr. Shankland's office (614-794-0033) and ask for the NICO Information Packett to be sent to you free of charge. You can also consult with Dr. Shankland. If you'd like to know more about Dr. Shankland, click on Biography.

The information in this article is not meant to be medical advice.�Treatment for a medical condition should come at the recommendation of your personal physician.

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